Provider Demographics
NPI:1851077309
Name:PETRIE, JONATHAN BRYAN (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:BRYAN
Last Name:PETRIE
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6195 25TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-4123
Mailing Address - Country:US
Mailing Address - Phone:904-238-0999
Mailing Address - Fax:
Practice Address - Street 1:9200 113TH ST
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-2800
Practice Address - Country:US
Practice Address - Phone:727-893-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDRPM2638122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist