Provider Demographics
NPI:1952450546
Name:DANIEL J PETROCELLA DDS PA
Entity Type:Organization
Organization Name:DANIEL J PETROCELLA DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:JESSEE
Authorized Official - Last Name:MORKUNAS
Authorized Official - Suffix:
Authorized Official - Credentials:CDA
Authorized Official - Phone:919-231-6024
Mailing Address - Street 1:4551 NEW BERN AVE
Mailing Address - Street 2:SUITE 195
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610
Mailing Address - Country:US
Mailing Address - Phone:919-231-6024
Mailing Address - Fax:919-231-8121
Practice Address - Street 1:4551 NEW BERN AVE
Practice Address - Street 2:STE 195
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610
Practice Address - Country:US
Practice Address - Phone:919-231-6024
Practice Address - Fax:919-231-8121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC62531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8996838Medicaid