Provider Demographics
NPI:1215747100
Name:PETTY DENTAL, PLLC
Entity type:Organization
Organization Name:PETTY DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:931-454-9499
Mailing Address - Street 1:2118 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-2208
Mailing Address - Country:US
Mailing Address - Phone:931-454-9499
Mailing Address - Fax:931-454-9499
Practice Address - Street 1:2118 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2208
Practice Address - Country:US
Practice Address - Phone:931-454-9499
Practice Address - Fax:931-454-9499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental