Provider Demographics
NPI:1295254035
Name:STUART PETTIJOHN DDS PLLC
Entity type:Organization
Organization Name:STUART PETTIJOHN DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTIJOHN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-890-0750
Mailing Address - Street 1:4500 CASCADE RD SE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3665
Mailing Address - Country:US
Mailing Address - Phone:616-942-8301
Mailing Address - Fax:
Practice Address - Street 1:4500 CASCADE RD SE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3665
Practice Address - Country:US
Practice Address - Phone:616-942-8301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020216122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty