Provider Demographics
NPI:1861525966
Name:PETROLL, PAUL S (DMD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:S
Last Name:PETROLL
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 739
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:WI
Mailing Address - Zip Code:54162-0739
Mailing Address - Country:US
Mailing Address - Phone:920-822-8111
Mailing Address - Fax:920-822-2198
Practice Address - Street 1:960 S. ST. AUGUSTINE ST
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:WI
Practice Address - Zip Code:54162-0739
Practice Address - Country:US
Practice Address - Phone:920-822-8111
Practice Address - Fax:920-822-2198
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4984122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist