Provider Demographics
NPI:1013993492
Name:PUCKETT, JOHN H (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:H
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72451-1209
Mailing Address - Country:US
Mailing Address - Phone:865-236-5888
Mailing Address - Fax:
Practice Address - Street 1:624 W. COURT ST.
Practice Address - Street 2:SUITE A
Practice Address - City:PARGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-4247
Practice Address - Country:US
Practice Address - Phone:870-236-5888
Practice Address - Fax:870-236-6888
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN81471223G0001X
AR34061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3206528Medicaid
AR176096608Medicaid