Provider Demographics
NPI:1568456705
Name:PUCKETT, C RAY JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:C
Middle Name:RAY
Last Name:PUCKETT
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 HWY 54 S
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88011
Mailing Address - Country:US
Mailing Address - Phone:575-443-8133
Mailing Address - Fax:575-267-1747
Practice Address - Street 1:2150 HWY 54 S
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88011
Practice Address - Country:US
Practice Address - Phone:575-443-8133
Practice Address - Fax:575-267-1747
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1726122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM84927Medicaid