Provider Demographics
NPI:1144323221
Name:PETREY, WILLIAM TODD (DMD)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:TODD
Last Name:PETREY
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:PO BOX 5131
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40745-5131
Mailing Address - Country:US
Mailing Address - Phone:606-843-6476
Mailing Address - Fax:606-843-6176
Practice Address - Street 1:2725 US HWY 25 N
Practice Address - Street 2:
Practice Address - City:EAST BERNSTADT
Practice Address - State:KY
Practice Address - Zip Code:40729
Practice Address - Country:US
Practice Address - Phone:606-843-6476
Practice Address - Fax:606-843-6176
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY72361223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY45001393OtherEPSDT
KY60072360Medicaid