Provider Demographics
NPI:1982448759
Name:PETTIT, TAYLOR V (DDS)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:V
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 1:197 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-2907
Mailing Address - Country:US
Mailing Address - Phone:208-971-2125
Mailing Address - Fax:
Practice Address - Street 1:167 E 200 N STE 3
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4049
Practice Address - Country:US
Practice Address - Phone:435-363-3584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14038757-99231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice