Healthcare Provider Details

I. General information

NPI: 1356667323
Provider Name (Legal Business Name): DENNIS G PETTIT DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 04/23/2010
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
45324-6358
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number30-01-8161
License Number StateOH

VIII. Authorized Official

Name: DR. DENNIS G. PETTIT
Title or Position: OWNER/PROVIDER
Credential: DDS
Phone: 937-878-8694