Provider Demographics
NPI:1679613418
Name:PETROS, JOAN (DMD)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:PETROS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 PLEASANT STREET
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-3236
Mailing Address - Country:US
Mailing Address - Phone:508-588-3020
Mailing Address - Fax:508-588-3020
Practice Address - Street 1:336 PLEASANT STREET
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-3236
Practice Address - Country:US
Practice Address - Phone:508-588-3020
Practice Address - Fax:508-588-3020
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA151701223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics