Provider Demographics
NPI:1710207097
Name:PETTIJOHN, STUART (DDS)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:
Last Name:PETTIJOHN
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 1:4500 CASCADE RD SE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3665
Mailing Address - Country:US
Mailing Address - Phone:616-942-8301
Mailing Address - Fax:
Practice Address - Street 1:4500 CASCADE RD SE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3665
Practice Address - Country:US
Practice Address - Phone:616-942-8301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020216122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist