Healthcare Provider Details

I. General information

NPI: 1356354765
Provider Name (Legal Business Name): DENNIS G PETTIT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1762 COMMERCE CENTER BLVD
FAIRBORN OH
45324-6358
US

IV. Provider business mailing address

1762 COMMERCE CENTER BLVD
FAIRBORN OH
45324
US

V. Phone/Fax

Practice location:
  • Phone: 937-878-8694
  • Fax:
Mailing address:
  • Phone: 937-878-8694
  • Fax: 937-878-1554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number30018161
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number30-01-8161
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: