Provider Demographics
NPI:1336253582
Name:PETKOVICH, BERNARD W (DDS PA)
Entity Type:Individual
Prefix:MR
First Name:BERNARD
Middle Name:W
Last Name:PETKOVICH
Suffix:
Gender:M
Credentials:DDS PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-2913
Mailing Address - Country:US
Mailing Address - Phone:870-425-9757
Mailing Address - Fax:870-424-9056
Practice Address - Street 1:500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2913
Practice Address - Country:US
Practice Address - Phone:870-425-9757
Practice Address - Fax:870-424-9056
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2371122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist