Provider Demographics
NPI:1669644282
Name:KAREN Y. PETTY, DDS, PA
Entity Type:Organization
Organization Name:KAREN Y. PETTY, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-875-1630
Mailing Address - Street 1:310 W MILLBROOK RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-4306
Mailing Address - Country:US
Mailing Address - Phone:919-875-1630
Mailing Address - Fax:919-875-1629
Practice Address - Street 1:310 W MILLBROOK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-4306
Practice Address - Country:US
Practice Address - Phone:919-875-1630
Practice Address - Fax:919-875-1629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6633122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC899016EOtherBCBS
NC899016EMedicaid
NC8996848Medicaid