Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 13801-00673 | MO |
NPI | 1235322108 |
---|---|
Provider Name | Dr. Glen H Petteway |
First Address | Springfield, MO 65804-3784 |
Second Address | Springfield, MO 65804-3784 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/08/2007 |
Last Update Date | 23/08/2007 |