Provider Demographics
NPI:1518096627
Name:PETRILLO, ANN B (DDS)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:B
Last Name:PETRILLO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:PA
Mailing Address - Zip Code:18651-3123
Mailing Address - Country:US
Mailing Address - Phone:570-779-5325
Mailing Address - Fax:570-779-0793
Practice Address - Street 1:580 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:PA
Practice Address - Zip Code:18651-3123
Practice Address - Country:US
Practice Address - Phone:570-779-5325
Practice Address - Fax:570-779-0793
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-023131-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice