Provider Demographics
NPI:1912329830
Name:PETTA, GLEN O (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:O
Last Name:PETTA
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 1:3201 PRESTON HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-2052
Mailing Address - Country:US
Mailing Address - Phone:817-312-9273
Mailing Address - Fax:
Practice Address - Street 1:3201 PRESTON HOLLOW RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-2052
Practice Address - Country:US
Practice Address - Phone:817-312-9273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-12
Last Update Date:2014-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12754122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist