Provider Demographics
NPI:1548725765
Name:S. ADAM TACKETT, DMD, MS, PLLC
Entity type:Organization
Organization Name:S. ADAM TACKETT, DMD, MS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:TACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:606-523-2000
Mailing Address - Street 1:727 W CUMBERLAND GAP PKWY STE D
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-5194
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:727 W CUMBERLAND GAP PKWY STE D
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-5194
Practice Address - Country:US
Practice Address - Phone:606-523-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty