MEDICARE: DR. JOHN E PETTY DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D50000004108	TN

General Provider Information

NPI Number	:	1558352997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN E PETTY DMD

Provider Business Mailing Address
First Line	:	2118 N JACKSON ST
Second Line	:
City	:	TULLAHOMA
State	:	TN
Zip	:	37388-2208
Country	:	US
Telephone Number	:	931-454-9499
Fax Number	:	931-454-0007

Provider Business Practice Location Address
First Line	:	2118 N JACKSON ST
Second Line	:
City	:	TULLAHOMA
State	:	TN
Zip	:	37388-2208
Country	:	US
Telephone Number	:	931-454-9499
Fax Number	:	931-454-0007

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/03/2005
Last Update Date	:	07/08/2007

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