Provider Demographics
NPI:1497108583
Name:PETRYNA, MARTA
Entity Type:Individual
Prefix:
First Name:MARTA
Middle Name:
Last Name:PETRYNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:EAST RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07073-1938
Mailing Address - Country:US
Mailing Address - Phone:201-500-9767
Mailing Address - Fax:
Practice Address - Street 1:124 PARK AVE
Practice Address - Street 2:
Practice Address - City:EAST RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07073-1938
Practice Address - Country:US
Practice Address - Phone:201-500-9767
Practice Address - Fax:201-935-2221
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02649200122300000X
PADS041014122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist