Provider Demographics
NPI:1679797112
Name:PETRO, GARY JOSEPH (DMD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JOSEPH
Last Name:PETRO
Suffix:
Gender:M
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:PO BOX 745
Mailing Address - Street 2:385 BRYAN ROAD SUITE 300
Mailing Address - City:SUMITON
Mailing Address - State:AL
Mailing Address - Zip Code:35148-0745
Mailing Address - Country:US
Mailing Address - Phone:205-648-6054
Mailing Address - Fax:
Practice Address - Street 1:385 BRYAN RD
Practice Address - Street 2:SUITE 300
Practice Address - City:SUMITON
Practice Address - State:AL
Practice Address - Zip Code:35148-3422
Practice Address - Country:US
Practice Address - Phone:205-648-6054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL37931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice