Provider Demographics
NPI:1184777146
Name:LEONARD J. PETITTI, DDS, INC
Entity type:Organization
Organization Name:LEONARD J. PETITTI, DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PETITTI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:1760-241-7084
Mailing Address - Street 1:12587 HESPERIA RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5847
Mailing Address - Country:US
Mailing Address - Phone:176-024-1708
Mailing Address - Fax:
Practice Address - Street 1:12587 HESPERIA RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5847
Practice Address - Country:US
Practice Address - Phone:176-024-1708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30739122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty