Provider Demographics
NPI:1356667323
Name:DENNIS G PETTIT DDS INC
Entity Type:Organization
Organization Name:DENNIS G PETTIT DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETTIT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:937-878-8694
Mailing Address - Street 1:1762 COMMERCE CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-6358
Mailing Address - Country:US
Mailing Address - Phone:937-878-8694
Mailing Address - Fax:
Practice Address - Street 1:1762 COMMERCE CENTER BLVD
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-6358
Practice Address - Country:US
Practice Address - Phone:937-878-8694
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-15
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-8161261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0695609Medicaid
OHU17952Medicare UPIN