Provider Demographics
NPI:1285734640
Name:PUCKETT, WANDA (DDS)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:WANDA
Other - Middle Name:
Other - Last Name:PUCKETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:2000 OPELOUSAS STREET
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601
Mailing Address - Country:US
Mailing Address - Phone:337-439-9983
Mailing Address - Fax:337-439-3224
Practice Address - Street 1:2000 OPELOUSAS STREET
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601
Practice Address - Country:US
Practice Address - Phone:337-439-9983
Practice Address - Fax:337-439-3224
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0366751122300000X
CT08746122300000X
LA61081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00749308Medicaid