Healthcare Provider Details

I. General information

NPI: 1982865812
Provider Name (Legal Business Name): JANNA LYNN PETTIGREW D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 07/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 W BROADWAY AVE
SULPHUR OK
73086-4409
US

IV. Provider business mailing address

925 W BROADWAY AVE
SULPHUR OK
73086-4409
US

V. Phone/Fax

Practice location:
  • Phone: 580-622-6144
  • Fax: 580-622-5350
Mailing address:
  • Phone: 580-622-6144
  • Fax: 580-622-5350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6034
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3728
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: