Healthcare Provider Details

I. General information

NPI: 1578819819
Provider Name (Legal Business Name): ANTHONY ROBERT PETRONE D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 A1A S SUITE A3
SAINT AUGUSTINE FL
32080-2916
US

IV. Provider business mailing address

2225 A1A S SUITE A3
SAINT AUGUSTINE FL
32080-2916
US

V. Phone/Fax

Practice location:
  • Phone: 904-471-7300
  • Fax:
Mailing address:
  • Phone: 904-471-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN19821
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: