Provider Demographics
NPI:1932113800
Name:PETASHNICK, MARVIN WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:WILLIAM
Last Name:PETASHNICK
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 1:5438 W LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095
Mailing Address - Country:US
Mailing Address - Phone:262-644-8289
Mailing Address - Fax:
Practice Address - Street 1:545 E JOHNSON ST
Practice Address - Street 2:
Practice Address - City:FONDULAC
Practice Address - State:WI
Practice Address - Zip Code:54935
Practice Address - Country:US
Practice Address - Phone:920-924-9090
Practice Address - Fax:920-921-0800
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40019521122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33519300Medicaid