Provider Demographics
NPI:1538498654
Name:PETRA V. ENZIEN, DMD, PLLC
Entity Type:Organization
Organization Name:PETRA V. ENZIEN, DMD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETRA
Authorized Official - Middle Name:VICTORIA
Authorized Official - Last Name:ENZIEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:518-664-2500
Mailing Address - Street 1:211 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MECHANICVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12118-1502
Mailing Address - Country:US
Mailing Address - Phone:518-664-2500
Mailing Address - Fax:518-664-2501
Practice Address - Street 1:211 PARK AVE
Practice Address - Street 2:
Practice Address - City:MECHANICVILLE
Practice Address - State:NY
Practice Address - Zip Code:12118-1502
Practice Address - Country:US
Practice Address - Phone:518-664-2500
Practice Address - Fax:518-664-2501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-19
Last Update Date:2009-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046460261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental