Provider Demographics
NPI:1790559110
Name:PETTY, VANESSA MICHELLE (RDH)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:MICHELLE
Last Name:PETTY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 ROYAL OAKS DR
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-5751
Mailing Address - Country:US
Mailing Address - Phone:501-844-6304
Mailing Address - Fax:
Practice Address - Street 1:1726 ROYAL OAKS DR
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-5751
Practice Address - Country:US
Practice Address - Phone:501-844-6304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1236124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist