MEDICARE: DR. JOHN PETKANAS 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	122300000X	Dentist	DI02019600	NJ

General Provider Information

NPI Number	:	1669587978
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN PETKANAS DDS

Provider Business Mailing Address
First Line	:	777 TERRACE AVE
Second Line	:	SUITE 302
City	:	HASBROUCK HEIGHTS
State	:	NJ
Zip	:	07604-3102
Country	:	US
Telephone Number	:	201-703-0100
Fax Number	:	201-703-0101

Provider Business Practice Location Address
First Line	:	777 TERRACE AVE
Second Line	:	SUITE 302
City	:	HASBROUCK HEIGHTS
State	:	NJ
Zip	:	07604-3102
Country	:	US
Telephone Number	:	201-703-0100
Fax Number	:	201-703-0101

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

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	05/08/2017

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