Provider Demographics
NPI:1851788913
Name:PETTENON, JAIME ANN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:ANN
Last Name:PETTENON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:JAIME
Other - Middle Name:ANN
Other - Last Name:CHOWANIEC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:45 S PARK BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6299
Mailing Address - Country:US
Mailing Address - Phone:708-307-5061
Mailing Address - Fax:
Practice Address - Street 1:45 S PARK BLVD STE 105
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-6299
Practice Address - Country:US
Practice Address - Phone:630-858-8755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-16
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190307541223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry