Provider Demographics
NPI:1558352997
Name:PETTY, JOHN E (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:PETTY
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 1:2118 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-2208
Mailing Address - Country:US
Mailing Address - Phone:931-454-9499
Mailing Address - Fax:931-454-0007
Practice Address - Street 1:2118 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2208
Practice Address - Country:US
Practice Address - Phone:931-454-9499
Practice Address - Fax:931-454-0007
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TND500000041081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice