Provider Demographics
NPI:1265767420
Name:PETTI, LISA MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:PETTI
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 1:29090 EUCLID AVE.
Mailing Address - Street 2:
Mailing Address - City:WICKLIFFE
Mailing Address - State:OH
Mailing Address - Zip Code:44092
Mailing Address - Country:US
Mailing Address - Phone:440-943-0266
Mailing Address - Fax:440-943-0292
Practice Address - Street 1:29090 EUCLID AVE.
Practice Address - Street 2:
Practice Address - City:WICKLIFFE
Practice Address - State:OH
Practice Address - Zip Code:44092
Practice Address - Country:US
Practice Address - Phone:440-943-0266
Practice Address - Fax:440-943-0292
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-06
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0176151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice