Provider Demographics
NPI:1922471622
Name:PUCKETT, DEAN
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 S VANDEVENTER AVE STE 700
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-3842
Mailing Address - Country:US
Mailing Address - Phone:314-203-1431
Mailing Address - Fax:
Practice Address - Street 1:1027 S VANDEVENTER AVE STE 700
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-3842
Practice Address - Country:US
Practice Address - Phone:314-203-1431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMONAVD3300006174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator