Provider Demographics
NPI:1306025119
Name:SACKETT, AUTUMN RENAE (DDS)
Entity Type:Individual
Prefix:DR
First Name:AUTUMN
Middle Name:RENAE
Last Name:SACKETT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 HILL STREET
Mailing Address - Street 2:
Mailing Address - City:BUCYRUS
Mailing Address - State:OH
Mailing Address - Zip Code:44820
Mailing Address - Country:US
Mailing Address - Phone:419-562-0203
Mailing Address - Fax:419-562-4467
Practice Address - Street 1:126 HILL STREET
Practice Address - Street 2:
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820
Practice Address - Country:US
Practice Address - Phone:419-562-0203
Practice Address - Fax:419-562-4467
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21265122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist