Provider Demographics
NPI:1407956055
Name:PETRIE, CHARLES R I (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:PETRIE
Suffix:I
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 1:6280 JACKSON DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-3434
Mailing Address - Country:US
Mailing Address - Phone:619-466-0194
Mailing Address - Fax:619-374-2110
Practice Address - Street 1:6280 JACKSON DR
Practice Address - Street 2:SUITE 6
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92119-3434
Practice Address - Country:US
Practice Address - Phone:619-466-0194
Practice Address - Fax:619-374-2110
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA245881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice