Healthcare Provider Details

I. General information

NPI: 1124620802
Provider Name (Legal Business Name): DAVID PETTIT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1584 NE 8TH ST STE 208
GRESHAM OR
97030-5746
US

IV. Provider business mailing address

1584 NE 8TH ST STE 208
GRESHAM OR
97030-5746
US

V. Phone/Fax

Practice location:
  • Phone: 503-230-0207
  • Fax: 503-230-0208
Mailing address:
  • Phone: 503-230-0207
  • Fax: 503-230-0208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: