Provider Demographics
NPI:1659475721
Name:TACKETT, CARL EDMOND (DMD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:EDMOND
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 1:419 TOWN MTN RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501
Mailing Address - Country:US
Mailing Address - Phone:606-432-0346
Mailing Address - Fax:606-432-0147
Practice Address - Street 1:419 TOWN MTN RD
Practice Address - Street 2:SUITE 105
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501
Practice Address - Country:US
Practice Address - Phone:606-432-0346
Practice Address - Fax:606-432-0147
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60042454Medicaid