Provider Demographics
NPI:1891076683
Name:JOSEPH S.PETREY PLLC
Entity Type:Organization
Organization Name:JOSEPH S.PETREY PLLC
Other - Org Name:PETREY AND NEWCOMB ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER /MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:STANLEY
Authorized Official - Last Name:PETREY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-451-0771
Mailing Address - Street 1:224 LANGDON ST
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-2342
Mailing Address - Country:US
Mailing Address - Phone:606-451-0771
Mailing Address - Fax:606-451-0780
Practice Address - Street 1:224 LANGDON ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-2342
Practice Address - Country:US
Practice Address - Phone:606-451-0771
Practice Address - Fax:606-451-0780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-07
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY82981223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1588838924Medicaid
KY60039286Medicaid
KY7100125620Medicaid