Provider Demographics
NPI:1740429828
Name:PETRUTSAS, LYLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LYLE
Middle Name:
Last Name:PETRUTSAS
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 1:3131 HARVARD AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-3437
Mailing Address - Country:US
Mailing Address - Phone:214-521-2258
Mailing Address - Fax:214-521-3425
Practice Address - Street 1:3131 HARVARD AVE STE 107
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-3437
Practice Address - Country:US
Practice Address - Phone:214-521-2258
Practice Address - Fax:214-521-3425
Is Sole Proprietor?:No
Enumeration Date:2009-02-12
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18774122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist