Provider Demographics
NPI:1689649931
Name:PUCKETT, TODD TRABOR (DMD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:TRABOR
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:943 CESERY BLVD
Mailing Address - Street 2:BUILDING # A
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-5635
Mailing Address - Country:US
Mailing Address - Phone:904-743-5604
Mailing Address - Fax:904-744-1490
Practice Address - Street 1:943 CESERY BLVD
Practice Address - Street 2:BUILDING # A
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-5635
Practice Address - Country:US
Practice Address - Phone:904-743-5604
Practice Address - Fax:904-744-1490
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010170951223S0112X
FLDN182171223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery