Provider Demographics
NPI:1902868649
Name:PETRY, MARK G (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:PETRY
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 1:219 S ADAMS STREET
Mailing Address - Street 2:
Mailing Address - City:WELSH
Mailing Address - State:LA
Mailing Address - Zip Code:70591
Mailing Address - Country:US
Mailing Address - Phone:337-734-4575
Mailing Address - Fax:337-734-4577
Practice Address - Street 1:219 S ADAMS STREET
Practice Address - Street 2:
Practice Address - City:WELSH
Practice Address - State:LA
Practice Address - Zip Code:70591
Practice Address - Country:US
Practice Address - Phone:337-734-4575
Practice Address - Fax:337-734-4577
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA45781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1845787Medicaid
588176OtherUNITED CONCORDIA
LAG7199OtherBLUE CROSS