Healthcare Provider Details

I. General information

NPI: 1851386726
Provider Name (Legal Business Name): JOHN F PETTUS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S CAMINO DEL RIO DURANGO MALL, F2
DURANGO CO
81301-6898
US

IV. Provider business mailing address

800 S CAMINO DEL RIO DURANGO MALL, F2
DURANGO CO
81301-6898
US

V. Phone/Fax

Practice location:
  • Phone: 970-259-2264
  • Fax: 970-259-7073
Mailing address:
  • Phone: 970-259-2264
  • Fax: 970-259-7073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number105637
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: