Healthcare Provider Details

I. General information

NPI: 1609846302
Provider Name (Legal Business Name): MARY T PETTIETTE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 AVIEMORE DR
PINEHURST NC
28374-9797
US

IV. Provider business mailing address

91 AVIEMORE DR
PINEHURST NC
28374-9797
US

V. Phone/Fax

Practice location:
  • Phone: 910-295-9950
  • Fax: 801-640-9294
Mailing address:
  • Phone: 910-295-9950
  • Fax: 801-640-9294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number6076
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: