Provider Demographics
NPI:1356700181
Name:GLEN H PETTEWAY, D.D.S., P.C.
Entity type:Organization
Organization Name:GLEN H PETTEWAY, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:H
Authorized Official - Last Name:PETTEWAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:417-887-7114
Mailing Address - Street 1:1200 E WOODHURST DR
Mailing Address - Street 2:BLD T, SUITE 300
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4261
Mailing Address - Country:US
Mailing Address - Phone:417-887-7114
Mailing Address - Fax:417-887-2882
Practice Address - Street 1:1200 E WOODHURST DR
Practice Address - Street 2:BLD T, SUITE 300
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4261
Practice Address - Country:US
Practice Address - Phone:417-887-7114
Practice Address - Fax:417-887-2882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO138011223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty