Provider Demographics
NPI:1760430730
Name:PETITO, ANTHONY ROCCO (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:ROCCO
Last Name:PETITO
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:400 MASSASOIT AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-2012
Mailing Address - Country:US
Mailing Address - Phone:401-919-5560
Mailing Address - Fax:401-919-5740
Practice Address - Street 1:400 MASSASOIT AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-2012
Practice Address - Country:US
Practice Address - Phone:401-919-5560
Practice Address - Fax:401-919-5740
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RI025521223S0112X
RIMD09730204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7006548Medicaid
U71328Medicare UPIN
RI7006548Medicaid