Provider Demographics
NPI:1780946822
Name:PETTIT, JEFFREY BRIAN (DDS)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:BRIAN
Last Name:PETTIT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 W FULTON ST
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-1007
Mailing Address - Country:US
Mailing Address - Phone:276-228-2777
Mailing Address - Fax:276-228-6219
Practice Address - Street 1:350 W FULTON ST
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1007
Practice Address - Country:US
Practice Address - Phone:276-228-2777
Practice Address - Fax:276-228-6219
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014136311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice