MEDICARE: DR. DENNIS MICHAEL PETRICOIN SR. DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DS017007	PA

General Provider Information

NPI Number	:	1588770176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DENNIS MICHAEL PETRICOIN SR. DDS

Provider Business Mailing Address
First Line	:	224 OAK HILL LN
Second Line	:
City	:	WYOMISSING
State	:	PA
Zip	:	19610-3215
Country	:	US
Telephone Number	:	610-374-9163
Fax Number	:

Provider Business Practice Location Address
First Line	:	224 OAK HILL LN
Second Line	:
City	:	WYOMISSING
State	:	PA
Zip	:	19610-3215
Country	:	US
Telephone Number	:	610-374-9163
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	07/08/2007

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