Provider Demographics
NPI:1689016982
Name:PETROUS, JEREK BRADFORD (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:JEREK
Middle Name:BRADFORD
Last Name:PETROUS
Suffix:
Gender:M
Credentials:DDS, MS
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Mailing Address - Street 1:30201 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-2284
Mailing Address - Country:US
Mailing Address - Phone:248-219-4154
Mailing Address - Fax:248-588-5610
Practice Address - Street 1:30201 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-2284
Practice Address - Country:US
Practice Address - Phone:248-219-4154
Practice Address - Fax:248-588-5610
Is Sole Proprietor?:No
Enumeration Date:2013-07-27
Last Update Date:2013-07-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI29010205121223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics