Provider Demographics
NPI:1619990058
Name:PETITTI, LEONARD JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:JOSEPH
Last Name:PETITTI
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 1:12587 HESPERIA RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5847
Mailing Address - Country:US
Mailing Address - Phone:760-241-7084
Mailing Address - Fax:
Practice Address - Street 1:12587 HESPERIA RD
Practice Address - Street 2:SUITE B
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5847
Practice Address - Country:US
Practice Address - Phone:760-241-7084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA307391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice