Healthcare Provider Details

I. General information

NPI: 1063571974
Provider Name (Legal Business Name): PAUL S PETRUNGARO DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 02/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 W FRONTAGE RD FL 2B
NORTHFIELD IL
60093-3467
US

IV. Provider business mailing address

330 W FRONTAGE RD FL 2B
NORTHFIELD IL
60093-3467
US

V. Phone/Fax

Practice location:
  • Phone: 847-386-6351
  • Fax: 847-386-7169
Mailing address:
  • Phone: 847-386-6351
  • Fax: 847-386-7169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.020118
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number021.001401
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: