Healthcare Provider Details

I. General information

NPI: 1407417140
Provider Name (Legal Business Name): REBECCA PETTS DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9601 CHESTER AVE
CLEVELAND OH
44106
US

IV. Provider business mailing address

30842 KILGOUR DR
WESTLAKE OH
44145-6835
US

V. Phone/Fax

Practice location:
  • Phone: 216-368-8665
  • Fax:
Mailing address:
  • Phone: 440-226-0097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberRES.004157
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: