Provider Demographics
NPI:1578666426
Name:TACKETT, JOHN C (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
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 1:102 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IN
Mailing Address - Zip Code:47167-1426
Mailing Address - Country:US
Mailing Address - Phone:812-883-4281
Mailing Address - Fax:812-883-4289
Practice Address - Street 1:102 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IN
Practice Address - Zip Code:47167-1426
Practice Address - Country:US
Practice Address - Phone:812-883-4281
Practice Address - Fax:812-883-4289
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009512A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery