Healthcare Provider Details

I. General information

NPI: 1376602318
Provider Name (Legal Business Name): CHRISTOPHER M PETRUNIC DMD., MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4164 CARMICHAEL RD
MONTGOMERY AL
36106-3600
US

IV. Provider business mailing address

4164 CARMICHAEL RD
MONTGOMERY AL
36106-3600
US

V. Phone/Fax

Practice location:
  • Phone: 334-277-2980
  • Fax: 334-277-2987
Mailing address:
  • Phone: 334-277-2980
  • Fax: 334-277-2987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number5152
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: