Provider Demographics
NPI:1215039334
Name:PETTA, WILLIAM J (DDS)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:J
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 1:1105 S 13TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-5767
Mailing Address - Country:US
Mailing Address - Phone:402-371-3745
Mailing Address - Fax:402-379-9265
Practice Address - Street 1:1105 S 13TH ST STE 200
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-5767
Practice Address - Country:US
Practice Address - Phone:402-371-3745
Practice Address - Fax:402-379-9265
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4826122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN470625718OtherDELTA
NE5437OtherBLUE CROSS BLUE SHIELD