Provider Demographics
NPI:1033285762
Name:PETRAITIS, THOMAS CARMEN (DMD)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:CARMEN
Last Name:PETRAITIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 HOSPITAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:DUBOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801
Mailing Address - Country:US
Mailing Address - Phone:814-375-1023
Mailing Address - Fax:814-375-7144
Practice Address - Street 1:101 HOSPITAL AVENUE
Practice Address - Street 2:
Practice Address - City:DUBOIS
Practice Address - State:PA
Practice Address - Zip Code:15801
Practice Address - Country:US
Practice Address - Phone:814-375-1023
Practice Address - Fax:814-375-7144
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS022374L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice