Provider Demographics
NPI:1689643264
Name:PETTIGREW, JAMES C JR (DMD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:C
Last Name:PETTIGREW
Suffix:JR
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:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-273-6775
Mailing Address - Fax:352-392-2507
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-273-6775
Practice Address - Fax:352-392-2507
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDTP312204E00000X, 1223X0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0008XDental ProvidersDentistOral and Maxillofacial Radiology
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73322900Medicaid
FL073322900Medicaid
FL67871YMedicare PIN
T85400Medicare UPIN
FL073322900Medicaid