Provider Demographics
NPI:1649756958
Name:PETROU, PETER (DMD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:PETROU
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BROOKLINE AVE UNIT 603
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3952
Mailing Address - Country:US
Mailing Address - Phone:331-218-8868
Mailing Address - Fax:
Practice Address - Street 1:644 AMERICAN LEGION HWY
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131
Practice Address - Country:US
Practice Address - Phone:617-553-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18580911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice