Provider Demographics
NPI:1699418921
Name:PETTY, TIMOTHY DAVID (DMD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DAVID
Last Name:PETTY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2554 S KRAMERIA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80222-7139
Mailing Address - Country:US
Mailing Address - Phone:720-434-0757
Mailing Address - Fax:
Practice Address - Street 1:1800 FORTINO BLVD UNIT 1
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1891
Practice Address - Country:US
Practice Address - Phone:719-545-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM390200000X
CODEN.002055341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program