Provider Demographics
NPI:1508071192
Name:PETTIS, CYRUS R (DMD)
Entity Type:Individual
Prefix:DR
First Name:CYRUS
Middle Name:R
Last Name:PETTIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N FLAGLER AVE
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33060-6636
Mailing Address - Country:US
Mailing Address - Phone:954-782-4001
Mailing Address - Fax:954-782-8702
Practice Address - Street 1:200 N FLAGLER AVE
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-6636
Practice Address - Country:US
Practice Address - Phone:954-782-4001
Practice Address - Fax:954-782-8702
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL75711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice