Provider Demographics
NPI:1093763724
Name:PETRIELLA, VICTOR M (DMD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:M
Last Name:PETRIELLA
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 1:177 IRVINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-2264
Mailing Address - Country:US
Mailing Address - Phone:973-762-5773
Mailing Address - Fax:973-762-5003
Practice Address - Street 1:177 IRVINGTON AVE
Practice Address - Street 2:
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-2264
Practice Address - Country:US
Practice Address - Phone:973-762-5773
Practice Address - Fax:973-762-5003
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ088981223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
U11908Medicare UPIN