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General NPI Number Information
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NPI Number | 1447410089
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Entity Type | Organization
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Legal Business Name | PUCKETT FAMILY DENTISTRY
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Dates
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Enumeration Date | 06/16/2008
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Last Update Date | 06/16/2008
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Provider Practice Location Address
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Address Line | 6181 HIGHWAY 18
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City | BRANDON
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State | MS
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Zip | 39042-0000
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Country | US
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Telephone | 601-825-0559
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Fax |
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Provider Business Mailing Address
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Address Line | 6181 HIGHWAY 18
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City | BRANDON
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State | MS
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Zip | 39042-0000
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Country | US
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Telephone | 601-825-0559
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Fax |
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. STEPHANIE TULLOS
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Credential | DMD
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Telephone | 601-825-0559
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 326503
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License Number State | MS
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