Provider Demographics
NPI:1730440934
Name:PICKETT, TYSON K (DDS)
Entity type:Individual
Prefix:DR
First Name:TYSON
Middle Name:K
Last Name:PICKETT
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 1:1135 KELLER PKWY
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-3614
Mailing Address - Country:US
Mailing Address - Phone:817-431-5514
Mailing Address - Fax:801-431-8048
Practice Address - Street 1:1135 KELLER PKWY
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3614
Practice Address - Country:US
Practice Address - Phone:817-431-5514
Practice Address - Fax:801-431-8048
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2016-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5888464-9922122300000X
TX31668122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist