Provider Demographics
NPI:1467486548
Name:PETRO, J JEROME (DMD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:JEROME
Last Name:PETRO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 MENOHER BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905
Mailing Address - Country:US
Mailing Address - Phone:814-536-8793
Mailing Address - Fax:814-536-7873
Practice Address - Street 1:909 MENOHER BOULEVARD
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905
Practice Address - Country:US
Practice Address - Phone:814-536-8793
Practice Address - Fax:814-536-7873
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS19044L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice