Provider Demographics
NPI:1518373018
Name:PETRUK, MARIEL (DDS)
Entity Type:Individual
Prefix:
First Name:MARIEL
Middle Name:
Last Name:PETRUK
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 1:416 SE 11TH COURT
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316
Mailing Address - Country:US
Mailing Address - Phone:954-787-6469
Mailing Address - Fax:954-787-6470
Practice Address - Street 1:416 SE 11TH COURT
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316
Practice Address - Country:US
Practice Address - Phone:954-787-6469
Practice Address - Fax:954-787-6470
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 207441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice