Basic Information
Provider Information | |||||||||
NPI: | 1285734640 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PUCKETT | ||||||||
FirstName: | WANDA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PUCKETT | ||||||||
OtherFirstName: | WANDA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DDS | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 2000 OPELOUSAS STREET | ||||||||
Address2: |   | ||||||||
City: | LAKE CHARLES | ||||||||
State: | LA | ||||||||
PostalCode: | 70601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3374399983 | ||||||||
FaxNumber: | 3374393224 | ||||||||
Practice Location | |||||||||
Address1: | 2000 OPELOUSAS STREET | ||||||||
Address2: |   | ||||||||
City: | LAKE CHARLES | ||||||||
State: | LA | ||||||||
PostalCode: | 70601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3374399983 | ||||||||
FaxNumber: | 3374393224 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2006 | ||||||||
LastUpdateDate: | 08/21/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 0366751 | NY | N |   | Dental Providers | Dentist |   | 122300000X | 08746 | CT | N |   | Dental Providers | Dentist |   | 1223G0001X | 6108 | LA | Y |   | Dental Providers | Dentist | General Practice |
ID Information
ID | Type | State | Issuer | Description | 00749308 | 05 | NY |   | MEDICAID |