Provider Demographics
NPI:1134414154
Name:PETITO ORAL SURGERY
Entity type:Organization
Organization Name:PETITO ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:ROCCO
Authorized Official - Last Name:PETITO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MD
Authorized Official - Phone:401-578-1688
Mailing Address - Street 1:400 MASSASOIT AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-2012
Mailing Address - Country:US
Mailing Address - Phone:401-578-1866
Mailing Address - Fax:508-336-6580
Practice Address - Street 1:400 MASSASOIT AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-2012
Practice Address - Country:US
Practice Address - Phone:401-578-1866
Practice Address - Fax:508-336-6580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-17
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI2552261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIU71328Medicare UPIN
U71328Medicare UPIN