Provider Demographics
NPI:1093372286
Name:PETROCELLI, JOHN (DMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PETROCELLI
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 1:120 BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-2115
Mailing Address - Country:US
Mailing Address - Phone:908-218-1788
Mailing Address - Fax:
Practice Address - Street 1:120 BRANCH RD
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807-2115
Practice Address - Country:US
Practice Address - Phone:908-218-1788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI008117001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice