Provider Demographics
NPI:1033264742
Name:HOM-MINNITI, PETULA (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETULA
Middle Name:
Last Name:HOM-MINNITI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 SAINT CLAIRE DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-5728
Mailing Address - Country:US
Mailing Address - Phone:678-990-8592
Mailing Address - Fax:678-990-8594
Practice Address - Street 1:270 SAINT CLAIRE DR
Practice Address - Street 2:SUITE 104
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-5728
Practice Address - Country:US
Practice Address - Phone:678-990-8592
Practice Address - Fax:678-990-8594
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0129001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9179479Medicaid
GA100300Medicaid
GA1765417OtherUNITED CONCORDIA