Provider Demographics
NPI:1922453877
Name:PETRIK, JAMES (DDS)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:PETRIK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:862 MEINECKE AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405
Mailing Address - Country:US
Mailing Address - Phone:805-544-1246
Mailing Address - Fax:805-544-1247
Practice Address - Street 1:862 MEINECKE AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405
Practice Address - Country:US
Practice Address - Phone:805-544-1246
Practice Address - Fax:805-544-1247
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20657122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist