Healthcare Provider Details

I. General information

NPI: 1306008057
Provider Name (Legal Business Name): STEVEN J PETRUZZI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 03/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 W BELL RD STE 18
PHOENIX AZ
85053-2749
US

IV. Provider business mailing address

4804 NE 65TH TER
KANSAS CITY MO
64119-1032
US

V. Phone/Fax

Practice location:
  • Phone: 602-843-1275
  • Fax:
Mailing address:
  • Phone: 760-218-1638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2009012760
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD008162
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: