Provider Demographics
NPI:1407950595
Name:PETRICH, DALE LAWRENCE (DDS)
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:LAWRENCE
Last Name:PETRICH
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 1:6720 FORT DENT WAY
Mailing Address - Street 2:SUITE #210
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98188
Mailing Address - Country:US
Mailing Address - Phone:206-433-5595
Mailing Address - Fax:206-433-0537
Practice Address - Street 1:6720 FORT DENT WAY
Practice Address - Street 2:SUITE #210
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188
Practice Address - Country:US
Practice Address - Phone:206-433-5595
Practice Address - Fax:206-433-0537
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00004785122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist