Healthcare Provider Details

I. General information

NPI: 1548705197
Provider Name (Legal Business Name): PETRUNICH ORAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2017
Last Update Date: 01/05/2017
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 HWY # 100
NEWARK DE
19702-3906
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1136
License Number StateDE

VIII. Authorized Official

Name: RAYMOND PETRUNICH
Title or Position: OWNER
Credential: DDS
Phone: 302-690-8822