Provider Demographics
NPI:1215998851
Name:PUCKETT, SCOTT A (DDS)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
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 1:1665 ALEX DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177
Mailing Address - Country:US
Mailing Address - Phone:937-382-8020
Mailing Address - Fax:937-382-8020
Practice Address - Street 1:1665 ALEX DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177
Practice Address - Country:US
Practice Address - Phone:937-382-8020
Practice Address - Fax:937-382-8020
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0211391223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Not Answered204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery