Provider Demographics
NPI:1790965374
Name:PUCKETT, GREGORY S (DMD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:S
Last Name:PUCKETT
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 1:517 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:VINE GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:40175-1461
Mailing Address - Country:US
Mailing Address - Phone:270-877-5553
Mailing Address - Fax:
Practice Address - Street 1:517 HIGHLAND AVE.
Practice Address - Street 2:
Practice Address - City:VINE GROVE
Practice Address - State:KY
Practice Address - Zip Code:40175-1461
Practice Address - Country:US
Practice Address - Phone:270-877-5553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6383122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist