Healthcare Provider Details

I. General information

NPI: 1356700181
Provider Name (Legal Business Name): GLEN H PETTEWAY, D.D.S., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 02/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E WOODHURST DR BLD T, SUITE 300
SPRINGFIELD MO
65804-4261
US

IV. Provider business mailing address

1200 E WOODHURST DR BLD T, SUITE 300
SPRINGFIELD MO
65804-4261
US

V. Phone/Fax

Practice location:
  • Phone: 417-887-7114
  • Fax: 417-887-2882
Mailing address:
  • Phone: 417-887-7114
  • Fax: 417-887-2882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number13801
License Number StateMO

VIII. Authorized Official

Name: DR. GLEN H PETTEWAY
Title or Position: OWNER
Credential: D.D.S.
Phone: 417-887-7114