Provider Demographics
NPI:1982865812
Name:PETTIGREW, JANNA LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JANNA
Middle Name:LYNN
Last Name:PETTIGREW
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:OK
Mailing Address - Zip Code:73086-4409
Mailing Address - Country:US
Mailing Address - Phone:580-622-6144
Mailing Address - Fax:580-622-5350
Practice Address - Street 1:925 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:OK
Practice Address - Zip Code:73086-4409
Practice Address - Country:US
Practice Address - Phone:580-622-6144
Practice Address - Fax:580-622-5350
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6034122300000X
AR37281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200212860AMedicaid