Healthcare Provider Details

I. General information

NPI: 1851077309
Provider Name (Legal Business Name): JONATHAN BRYAN PETRIE DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 113TH ST
SEMINOLE FL
33772-2800
US

IV. Provider business mailing address

6195 25TH AVE N
ST PETERSBURG FL
33710-4123
US

V. Phone/Fax

Practice location:
  • Phone: 727-893-5050
  • Fax:
Mailing address:
  • Phone: 904-238-0999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDRPM2638
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: