Provider Demographics
NPI:1871894907
Name:PETTY, STEPHEN (DDS)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:PETTY
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 1:6065 MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-1835
Mailing Address - Country:US
Mailing Address - Phone:915-771-7966
Mailing Address - Fax:
Practice Address - Street 1:6065 MONTANA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-1835
Practice Address - Country:US
Practice Address - Phone:915-771-7966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-05
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27160122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist