Provider Demographics
NPI:1992914410
Name:PETTENGILL, CRAIG ALAN (DDS)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:ALAN
Last Name:PETTENGILL
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 1:1660 WESTWOOD DR STE E
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-5100
Mailing Address - Country:US
Mailing Address - Phone:408-269-9180
Mailing Address - Fax:408-269-9199
Practice Address - Street 1:1660 WESTWOOD DR STE E
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-5100
Practice Address - Country:US
Practice Address - Phone:408-269-9180
Practice Address - Fax:408-269-9199
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30413122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist