Provider Demographics
NPI:1649220526
Name:PETRUNICH, RAYMOND WAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:WAYNE
Last Name:PETRUNICH
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 1:2444 PULASKI HIGHWAY
Mailing Address - Street 2:#100
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-3906
Mailing Address - Country:US
Mailing Address - Phone:302-836-3565
Mailing Address - Fax:302-836-0868
Practice Address - Street 1:2444 PULASKI HWY
Practice Address - Street 2:#100
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-3906
Practice Address - Country:US
Practice Address - Phone:302-836-3565
Practice Address - Fax:302-836-0868
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG1-0011361223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE000014361Medicaid
DEU91771Medicare UPIN
DE000014361Medicaid