Provider Demographics
NPI:1578783023
Name:PETRELLA, MARTIN ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:ANTHONY
Last Name:PETRELLA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 NASSAU BLVD SOUTH
Mailing Address - Street 2:
Mailing Address - City:WEST HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11552
Mailing Address - Country:US
Mailing Address - Phone:516-489-0344
Mailing Address - Fax:516-489-0677
Practice Address - Street 1:72 NASSAU BLVD SO
Practice Address - Street 2:
Practice Address - City:WEST HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11552
Practice Address - Country:US
Practice Address - Phone:516-489-0344
Practice Address - Fax:516-489-0677
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02813011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice