Provider Demographics
NPI:1588672588
Name:THOMAS PETNUCH DMD PC
Entity Type:Organization
Organization Name:THOMAS PETNUCH DMD PC
Other - Org Name:WILLOWBROOK DENTAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PETNUCH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:724-836-6884
Mailing Address - Street 1:259 OLD ROUTE 30
Mailing Address - Street 2:SUITE D
Mailing Address - City:GREENBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601
Mailing Address - Country:US
Mailing Address - Phone:724-836-6884
Mailing Address - Fax:724-836-4616
Practice Address - Street 1:259 OLD ROUTE 30
Practice Address - Street 2:SUITE D
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601
Practice Address - Country:US
Practice Address - Phone:724-836-6884
Practice Address - Fax:724-836-4616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0350011223G0001X
PADS021701L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty