Provider Demographics
NPI:1477859130
Name:L.G. PUCKETT D.D.S.
Entity Type:Organization
Organization Name:L.G. PUCKETT D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LUTHER
Authorized Official - Middle Name:G
Authorized Official - Last Name:PUCKETT
Authorized Official - Suffix:IV
Authorized Official - Credentials:DDS
Authorized Official - Phone:931-823-3754
Mailing Address - Street 1:508 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:38570-1539
Mailing Address - Country:US
Mailing Address - Phone:931-823-3754
Mailing Address - Fax:931-823-3739
Practice Address - Street 1:508 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TN
Practice Address - Zip Code:38570-1539
Practice Address - Country:US
Practice Address - Phone:931-823-3754
Practice Address - Fax:931-823-3739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-28
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN85481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5440979Medicaid