Provider Demographics
NPI:1417565193
Name:PETTY, JACKSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:
Last Name:PETTY
Suffix:
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 1:128 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2290
Mailing Address - Country:US
Mailing Address - Phone:719-587-1001
Mailing Address - Fax:719-589-5722
Practice Address - Street 1:128 MARKET ST
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2290
Practice Address - Country:US
Practice Address - Phone:719-587-1001
Practice Address - Fax:719-589-5722
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN114231223G0001X
390200000X
CO2046571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program