Provider Demographics
NPI:1447410089
Name:PUCKETT FAMILY DENTISTRY
Entity Type:Organization
Organization Name:PUCKETT FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TULLOS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-825-0559
Mailing Address - Street 1:6181 HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-0000
Mailing Address - Country:US
Mailing Address - Phone:601-825-0559
Mailing Address - Fax:
Practice Address - Street 1:6181 HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-0000
Practice Address - Country:US
Practice Address - Phone:601-825-0559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS326503122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty