Provider Demographics
NPI:1043694920
Name:PUCKETT DENTAL LLC
Entity Type:Organization
Organization Name:PUCKETT DENTAL LLC
Other - Org Name:POCAHONTAS SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:HARTLEY
Authorized Official - Last Name:PUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-236-5888
Mailing Address - Street 1:1041HWY. 67 N.
Mailing Address - Street 2:
Mailing Address - City:POCAHONTAS
Mailing Address - State:AR
Mailing Address - Zip Code:72455
Mailing Address - Country:US
Mailing Address - Phone:870-236-5888
Mailing Address - Fax:
Practice Address - Street 1:1041 HIGHWAY 67 NORTH
Practice Address - Street 2:
Practice Address - City:POCAHONTAS
Practice Address - State:AR
Practice Address - Zip Code:72455
Practice Address - Country:US
Practice Address - Phone:870-236-5888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PUCKETT DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3406261QD0000X
AR4053261QD0000X
AR3684261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR176096608Medicaid
MO1669608741Medicaid