Provider Demographics
NPI:1457996712
Name:PETTIS, DENNIS WAYNE
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:WAYNE
Last Name:PETTIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E HOMESTEAD AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28152-9502
Mailing Address - Country:US
Mailing Address - Phone:704-477-0852
Mailing Address - Fax:704-867-1414
Practice Address - Street 1:420 E HOMESTEAD AVE
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28152-9502
Practice Address - Country:US
Practice Address - Phone:704-477-0852
Practice Address - Fax:704-867-1414
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty