Healthcare Provider Details

I. General information

NPI: 1699098350
Provider Name (Legal Business Name): PATRICK JOSEPH PETLEY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2010
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3445 HENDERSON DR
JACKSONVILLE NC
28546-5233
US

IV. Provider business mailing address

3445 HENDERSON DR
JACKSONVILLE NC
28546-5233
US

V. Phone/Fax

Practice location:
  • Phone: 910-347-1283
  • Fax:
Mailing address:
  • Phone: 910-347-1283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12078
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS024517L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: