Healthcare Provider Details

I. General information

NPI: 1437211448
Provider Name (Legal Business Name): JOHN ADAM PETTY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 W MCMILLAN ST
MARSHFIELD WI
54449-6013
US

IV. Provider business mailing address

9145 OLYMPIA ST
GOLDEN VALLEY MN
55427-3764
US

V. Phone/Fax

Practice location:
  • Phone: 715-387-1702
  • Fax:
Mailing address:
  • Phone: 231-799-5648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5543-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: