Provider Demographics
NPI:1346451812
Name:PETROS, DHAFIR JALAL
Entity Type:Individual
Prefix:
First Name:DHAFIR
Middle Name:JALAL
Last Name:PETROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4844 UNIVERSITY AVE
Mailing Address - Street 2:SUIT B
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-8021
Mailing Address - Country:US
Mailing Address - Phone:619-285-5010
Mailing Address - Fax:619-285-5013
Practice Address - Street 1:4844 UNIVERSITY AVE
Practice Address - Street 2:SUIT B
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-8021
Practice Address - Country:US
Practice Address - Phone:619-285-5010
Practice Address - Fax:619-285-5013
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47154122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD47154Medicare ID - Type UnspecifiedDENTIST