Provider Demographics
NPI:1922274745
Name:PETULLA, KRISTIN BETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:BETH
Last Name:PETULLA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053
Mailing Address - Country:US
Mailing Address - Phone:856-983-4846
Mailing Address - Fax:856-983-1054
Practice Address - Street 1:43 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053
Practice Address - Country:US
Practice Address - Phone:856-983-4846
Practice Address - Fax:856-983-1054
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI19324122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist