Provider Demographics
NPI:1356759112
Name:PETRIK, DAVID (DDS)
Entity type:Individual
Prefix:
First Name:DAVID
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 1:5341 GRAND BLVD
Mailing Address - Street 2:STE 108
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-4004
Mailing Address - Country:US
Mailing Address - Phone:727-847-6453
Mailing Address - Fax:727-847-6447
Practice Address - Street 1:4843 US HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-4252
Practice Address - Country:US
Practice Address - Phone:727-847-6453
Practice Address - Fax:727-847-6447
Is Sole Proprietor?:No
Enumeration Date:2014-07-24
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN131501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice