Active NPI
Timothy David Petty, DMD
- General Practice Dentistry
- Pueblo, CO
National Provider Identifier
1699418921
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- DEN.00205534
- Practice address
- 1800 Fortino Blvd Unit 1
Pueblo, CO 81008-1891 - Phone
- (719) 545-1400
- NPI assigned
- Apr 14, 2022
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Student in an Organized Health Care Education/Training Program | 390200000X | NM | ||
| General Practice Dentistry | 1223G0001X | DEN.00205534 | CO | Primary |
Addresses
Primary practice location
1800 Fortino Blvd Unit 1
Pueblo, CO 81008-1891
Mailing address
2554 S Krameria St
Denver, CO 80222-7139
Phone (720) 434-0757
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DEN.00205534 | CO | MD | General Practice Dentistry |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Excellence in Dentistry of Pueblo One PLLC | General Practice | Past | Accepting new patients |
| Advantage Dental Group | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Dentist
- Pueblo, CO
- NPI 1205276128
-
- General Practice Dentistry
- Pueblo, CO
- NPI 1730545757
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1649894400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1688688000000",
"number": "1699418921",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2554 S KRAMERIA ST",
"city": "DENVER",
"state": "CO",
"postal_code": "802227139",
"telephone_number": "720-434-0757"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1800 FORTINO BLVD UNIT 1",
"city": "PUEBLO",
"state": "CO",
"postal_code": "810081891",
"telephone_number": "719-545-1400"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETTY",
"first_name": "TIMOTHY",
"middle_name": "DAVID",
"credential": "DMD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2022-04-14",
"last_updated": "2023-07-07",
"certification_date": "2023-07-07",
"status": "A"
},
"taxonomies": [
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": "NM",
"license": null,
"primary": false
},
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "CO",
"license": "DEN.00205534",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Pueblo, CO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 7, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.