Provider Demographics
NPI:1831590231
Name:PETRI, ODETA (DDS)
Entity type:Individual
Prefix:DR
First Name:ODETA
Middle Name:
Last Name:PETRI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 S PLAZA DR
Mailing Address - Street 2:#KPH2
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-7434
Mailing Address - Country:US
Mailing Address - Phone:619-610-8388
Mailing Address - Fax:
Practice Address - Street 1:2231 S BRISTOL ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-5124
Practice Address - Country:US
Practice Address - Phone:714-556-1001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-05
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63838122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist