Healthcare Provider Details

I. General information

NPI: 1437209533
Provider Name (Legal Business Name): JONATHAN S PETROVER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 10/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2465 S STATE ROAD 7 SUITE 600
WELLINGTON FL
33414-9324
US

IV. Provider business mailing address

2465 S STATE ROAD 7 SUITE 600
WELLINGTON FL
33414-9324
US

V. Phone/Fax

Practice location:
  • Phone: 561-795-3055
  • Fax: 561-795-3755
Mailing address:
  • Phone: 561-795-3055
  • Fax: 561-795-3755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN14233
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: