Provider Demographics
NPI:1669608139
Name:TACKITT, ALISHA DAWN (DMD)
Entity type:Individual
Prefix:DR
First Name:ALISHA
Middle Name:DAWN
Last Name:TACKITT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 INDIAN MOUND DR
Mailing Address - Street 2:C COLONY SHOPPES
Mailing Address - City:MT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-1300
Mailing Address - Country:US
Mailing Address - Phone:859-498-2356
Mailing Address - Fax:
Practice Address - Street 1:1107 INDIAN MOUND DR
Practice Address - Street 2:C COLONY SHOPPES
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-1300
Practice Address - Country:US
Practice Address - Phone:859-498-2356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY87671223G0001X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No174400000XOther Service ProvidersSpecialist