Healthcare Provider Details

I. General information

NPI: 1679579064
Provider Name (Legal Business Name): KATHLEEN A PETIT DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 WALES AVE NW STE B
MASSILLON OH
44646-2366
US

IV. Provider business mailing address

2400 WALES AVE NW STE B
MASSILLON OH
44646-2366
US

V. Phone/Fax

Practice location:
  • Phone: 330-833-2619
  • Fax: 330-833-6987
Mailing address:
  • Phone: 330-833-2619
  • Fax: 330-833-6987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30-02-0367
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: