Provider Demographics
NPI:1235353277
Name:TACKETT, JARREL LEELAND (DMD)
Entity Type:Individual
Prefix:
First Name:JARREL
Middle Name:LEELAND
Last Name:TACKETT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 409
Mailing Address - Street 2:221 CROWE AVE
Mailing Address - City:MARS
Mailing Address - State:PA
Mailing Address - Zip Code:16046-0409
Mailing Address - Country:US
Mailing Address - Phone:724-625-2530
Mailing Address - Fax:724-625-2590
Practice Address - Street 1:221 CROWE AVE
Practice Address - Street 2:
Practice Address - City:MARS
Practice Address - State:PA
Practice Address - Zip Code:16046-0409
Practice Address - Country:US
Practice Address - Phone:724-625-2530
Practice Address - Fax:724-625-2590
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0269009L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice