Provider Demographics
NPI:1164683892
Name:PETULA, CARMEN RALPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:RALPH
Last Name:PETULA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2156
Mailing Address - Country:US
Mailing Address - Phone:856-983-4846
Mailing Address - Fax:856-983-1054
Practice Address - Street 1:43 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2156
Practice Address - Country:US
Practice Address - Phone:856-983-4846
Practice Address - Fax:856-983-1054
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ83311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice