Provider Demographics
NPI:1790853653
Name:GUS CHARLES PETRAS DDS
Entity Type:Organization
Organization Name:GUS CHARLES PETRAS DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GUS
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:PETRAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:530-222-2473
Mailing Address - Street 1:400 HARTNELL AVENUE
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-1848
Mailing Address - Country:US
Mailing Address - Phone:530-222-2473
Mailing Address - Fax:530-222-3718
Practice Address - Street 1:400 HARTNELL AVENUE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-1848
Practice Address - Country:US
Practice Address - Phone:530-222-2473
Practice Address - Fax:530-222-3718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA221711223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB2217101OtherMEDICAL DENTICAL