Provider Demographics
NPI:1679828081
Name:PETRILLA, GREGORY D (DMD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:D
Last Name:PETRILLA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SHENANGO AVE
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:PA
Mailing Address - Zip Code:16146-1503
Mailing Address - Country:US
Mailing Address - Phone:724-465-6100
Mailing Address - Fax:724-465-6110
Practice Address - Street 1:590 INDIAN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3600
Practice Address - Country:US
Practice Address - Phone:724-465-6100
Practice Address - Fax:724-465-6110
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS039264122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1027479290003Medicaid
PA1027479290001Medicaid
PA102747929Medicaid
PA1027479290002Medicaid