Provider Demographics
NPI:1477699031
Name:PETTIGREW, J. LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:J.
Middle Name:LEE
Last Name:PETTIGREW
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 1:201 PLAYERS CIRCLE
Mailing Address - Street 2:SUITE #100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092
Mailing Address - Country:US
Mailing Address - Phone:817-481-4888
Mailing Address - Fax:
Practice Address - Street 1:201 PLAYERS CIRCLE
Practice Address - Street 2:SUITE #100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092
Practice Address - Country:US
Practice Address - Phone:817-481-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX159431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice