Provider Demographics
NPI:1235865221
Name:PETRIN, AMANDA NICOLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:NICOLE
Last Name:PETRIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 SOUND DR
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-2932
Mailing Address - Country:US
Mailing Address - Phone:570-862-3684
Mailing Address - Fax:
Practice Address - Street 1:2830 HWY 52
Practice Address - Street 2:STE 360
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461
Practice Address - Country:US
Practice Address - Phone:439-904-7158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT135341223G0001X
SCDGD.106561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice