Provider Demographics
NPI:1487671301
Name:PETRACCA, JOAN (DMD)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:PETRACCA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 LEXINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-8219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 LEXINGTON ST
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-8219
Practice Address - Country:US
Practice Address - Phone:508-872-1627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA171411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice