Healthcare Provider Details

I. General information

NPI: 1689643264
Provider Name (Legal Business Name): JAMES C PETTIGREW JR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

PO BOX 918025
ORLANDO FL
32891-8025
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-6775
  • Fax: 352-392-2507
Mailing address:
  • Phone: 352-273-6775
  • Fax: 352-392-2507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDTP312
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License NumberDTP312
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: