Provider Demographics
NPI:1235322108
Name:PETTEWAY, GLEN H (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:H
Last Name:PETTEWAY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1200 E WOODHURST
Mailing Address - Street 2:STE T300
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-3784
Mailing Address - Country:US
Mailing Address - Phone:417-887-7114
Mailing Address - Fax:417-887-2882
Practice Address - Street 1:1200 E WOODHURST
Practice Address - Street 2:STE T300
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-3784
Practice Address - Country:US
Practice Address - Phone:417-887-7114
Practice Address - Fax:417-887-2882
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO13801-006731223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics