Provider Demographics
NPI:1356930648
Name:PETTY, DEREK ANDREW (DDS)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:ANDREW
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 1:2801 LIVE OAK ST APT 5203
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-5732
Mailing Address - Country:US
Mailing Address - Phone:903-519-9134
Mailing Address - Fax:
Practice Address - Street 1:4050 W INTERSTATE 20
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-1435
Practice Address - Country:US
Practice Address - Phone:903-519-9134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist