Provider Demographics
NPI:1467610519
Name:DEPETRIS, BRIAN G (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:G
Last Name:DEPETRIS
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 1:1011 CLIFTON AVE
Mailing Address - Street 2:SUITE 2-A
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-3518
Mailing Address - Country:US
Mailing Address - Phone:973-365-2620
Mailing Address - Fax:973-365-2621
Practice Address - Street 1:1011 CLIFTON AVE
Practice Address - Street 2:SUITE 2-A
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3518
Practice Address - Country:US
Practice Address - Phone:973-365-2620
Practice Address - Fax:973-365-2621
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D1011873001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice