Provider Demographics
NPI:1881827780
Name:PETRA DIAGNOSTICS
Entity Type:Organization
Organization Name:PETRA DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:W
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:401-295-0260
Mailing Address - Street 1:350 KINGSTOWN RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:NARRAGANSETT
Mailing Address - State:RI
Mailing Address - Zip Code:02882-3262
Mailing Address - Country:US
Mailing Address - Phone:401-284-3500
Mailing Address - Fax:401-284-3502
Practice Address - Street 1:350 KINGSTOWN RD
Practice Address - Street 2:SUITE 203
Practice Address - City:NARRAGANSETT
Practice Address - State:RI
Practice Address - Zip Code:02882-3262
Practice Address - Country:US
Practice Address - Phone:401-284-3500
Practice Address - Fax:401-284-3502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-26
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI2494261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental