1619364114 NPI number — J LEE PETTIGREW DDS PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619364114 NPI number — J LEE PETTIGREW DDS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J LEE PETTIGREW DDS PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619364114
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 PLAYERS CIR
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
SOUTHLAKE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76092-6944
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-481-4888
Provider Business Mailing Address Fax Number:
817-421-7370

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 PLAYERS CIR
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
SOUTHLAKE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76092-6944
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-481-4888
Provider Business Practice Location Address Fax Number:
817-421-7370
Provider Enumeration Date:
04/22/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PETTIGREW
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
817-481-4888

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  15943 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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