Healthcare Provider Details

I. General information

NPI: 1447410089
Provider Name (Legal Business Name): PUCKETT FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6181 HIGHWAY 18
BRANDON MS
39042-0000
US

IV. Provider business mailing address

6181 HIGHWAY 18
BRANDON MS
39042-0000
US

V. Phone/Fax

Practice location:
  • Phone: 601-825-0559
  • Fax:
Mailing address:
  • Phone: 601-825-0559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number326503
License Number StateMS

VIII. Authorized Official

Name: DR. STEPHANIE TULLOS
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 601-825-0559