Provider Demographics
NPI:1023178316
Name:PETTICOLAS, AUGUSTUS ALLEN JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:AUGUSTUS
Middle Name:ALLEN
Last Name:PETTICOLAS
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1824
Mailing Address - Country:US
Mailing Address - Phone:434-528-3375
Mailing Address - Fax:434-528-2293
Practice Address - Street 1:1342 PARK AVE
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1824
Practice Address - Country:US
Practice Address - Phone:434-528-3375
Practice Address - Fax:434-528-2293
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA049771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice