Provider Demographics
NPI:1376535104
Name:TACKETT, DANNY KEITH (DMD)
Entity Type:Individual
Prefix:DR
First Name:DANNY
Middle Name:KEITH
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 1:2707 JACKSBORO PIKE
Mailing Address - Street 2:SUITE #4
Mailing Address - City:JACKSBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37757-2752
Mailing Address - Country:US
Mailing Address - Phone:423-566-0401
Mailing Address - Fax:423-566-0423
Practice Address - Street 1:2707 JACKSBORO PIKE
Practice Address - Street 2:SUITE #4
Practice Address - City:JACKSBORO
Practice Address - State:TN
Practice Address - Zip Code:37757-2752
Practice Address - Country:US
Practice Address - Phone:423-566-0401
Practice Address - Fax:423-566-0423
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2007-09-18
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2007-09-18
Provider Licenses
StateLicense IDTaxonomies
TNDS7240122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist