Provider Demographics
NPI:1609484138
Name:PETRICH, TAYLOR R (DMD)
Entity Type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:R
Last Name:PETRICH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 MONTICELLO PL
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3133
Mailing Address - Country:US
Mailing Address - Phone:256-642-6031
Mailing Address - Fax:
Practice Address - Street 1:212 E MARKET ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:IL
Practice Address - Zip Code:62294-1512
Practice Address - Country:US
Practice Address - Phone:618-283-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032821122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist