Provider Demographics
NPI:1134358476
Name:PETRICIG, HEATHER N (DDS)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:N
Last Name:PETRICIG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:HEATHER
Other - Middle Name:N
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1101 S COLUMBIA RD STE B
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4055
Mailing Address - Country:US
Mailing Address - Phone:218-230-4352
Mailing Address - Fax:701-795-1102
Practice Address - Street 1:1101 S COLUMBIA RD STE B
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4055
Practice Address - Country:US
Practice Address - Phone:218-230-4352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-08
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI64191223G0001X
ND2083122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41564Medicaid