Healthcare Provider Details

I. General information

NPI: 1649220526
Provider Name (Legal Business Name): RAYMOND WAYNE PETRUNICH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2444 PULASKI HWY #100
NEWARK DE
19702-3906
US

IV. Provider business mailing address

2444 PULASKI HIGHWAY #100
NEWARK DE
19702-3906
US

V. Phone/Fax

Practice location:
  • Phone: 302-836-3565
  • Fax: 302-836-0868
Mailing address:
  • Phone: 302-836-3565
  • Fax: 302-836-0868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberG1-001136
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: