Provider Demographics
NPI:1144956137
Name:PETTY, DON RAY (DDS)
Entity type:Individual
Prefix:
First Name:DON
Middle Name:RAY
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 1:12303 FORT CHADBORNE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-4433
Mailing Address - Country:US
Mailing Address - Phone:210-995-5123
Mailing Address - Fax:
Practice Address - Street 1:2358 E SOUTHCROSS BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223-2263
Practice Address - Country:US
Practice Address - Phone:210-364-2561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-01
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX388021223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist