Provider Demographics
NPI:1710059399
Name:PETRACEK, JUSTIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:PETRACEK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9100 W 100TH AVE
Mailing Address - Street 2:#5B
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80021-6811
Mailing Address - Country:US
Mailing Address - Phone:303-420-9720
Mailing Address - Fax:303-420-0086
Practice Address - Street 1:9100 W 100TH AVE
Practice Address - Street 2:#5B
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80021-6811
Practice Address - Country:US
Practice Address - Phone:303-420-9720
Practice Address - Fax:303-420-0086
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8925122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist