Provider Demographics
NPI:1639305170
Name:PUCKETT, WILLIAM ALAN JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ALAN
Last Name:PUCKETT
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1408 PETERMAN DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3432
Mailing Address - Country:US
Mailing Address - Phone:318-427-9220
Mailing Address - Fax:318-442-1811
Practice Address - Street 1:1408 PETERMAN DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3432
Practice Address - Country:US
Practice Address - Phone:318-427-9220
Practice Address - Fax:318-442-1811
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA59781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1859788Medicaid