Basic Information
| Provider Information | |||||||||
| NPI: | 1629457262 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETTEY | ||||||||
| FirstName: | DIX | ||||||||
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| Credential: | O.D., M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 65 S MARIO CAPECCHI DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015812352 | ||||||||
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| Practice Location | |||||||||
| Address1: | 65 S MARIO CAPECCHI DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015812352 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2015 | ||||||||
| LastUpdateDate: | 11/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 9418444-9934 | UT | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.