Provider Demographics
NPI:1336106483
Name:PETRICK, DAVID LEIGH (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LEIGH
Last Name:PETRICK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:L
Other - Last Name:PETRICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1504 LINCOLN WAY
Mailing Address - Street 2:
Mailing Address - City:WHITE OAK
Mailing Address - State:PA
Mailing Address - Zip Code:15131
Mailing Address - Country:US
Mailing Address - Phone:412-672-4100
Mailing Address - Fax:412-672-7443
Practice Address - Street 1:1504 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:WHITE OAK
Practice Address - State:PA
Practice Address - Zip Code:15131
Practice Address - Country:US
Practice Address - Phone:412-672-4100
Practice Address - Fax:412-672-7443
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS018729L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
T27136Medicare UPIN