Provider Demographics
NPI:1760574701
Name:PETTIT, MARK LOUIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LOUIS
Last Name:PETTIT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 E 100 S
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1501
Mailing Address - Country:US
Mailing Address - Phone:801-328-1633
Mailing Address - Fax:801-328-4065
Practice Address - Street 1:1060 E 100 S
Practice Address - Street 2:SUITE 302
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1501
Practice Address - Country:US
Practice Address - Phone:801-328-1633
Practice Address - Fax:801-328-4065
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT27635799221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice