Provider Demographics
NPI:1306936844
Name:TACKETT, DENVER DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:DENVER
Middle Name:DAVID
Last Name:TACKETT
Suffix:
Gender:M
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:P O BOX 596
Mailing Address - Street 2:
Mailing Address - City:MCDOWELL
Mailing Address - State:KY
Mailing Address - Zip Code:41647
Mailing Address - Country:US
Mailing Address - Phone:606-377-2801
Mailing Address - Fax:606-377-9294
Practice Address - Street 1:RT 122 TACKETT COMPLEX
Practice Address - Street 2:
Practice Address - City:MCDOWELL
Practice Address - State:KY
Practice Address - Zip Code:41647
Practice Address - Country:US
Practice Address - Phone:606-377-2801
Practice Address - Fax:606-377-9294
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5889122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist