Provider Demographics
NPI:1629209408
Name:PETTUS, RAYMOND LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:LEE
Last Name:PETTUS
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 1:2716 MARILYN RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1222
Mailing Address - Country:US
Mailing Address - Phone:719-271-9664
Mailing Address - Fax:
Practice Address - Street 1:2716 MARILYN RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1222
Practice Address - Country:US
Practice Address - Phone:719-271-9664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO104187122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist