Healthcare Provider Details

I. General information

NPI: 1487623559
Provider Name (Legal Business Name): DAVID M PETRARCA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 HIGH ST
MEDFORD MA
02155-3813
US

IV. Provider business mailing address

33 SUMMIT AVE
WALTHAM MA
02453-7731
US

V. Phone/Fax

Practice location:
  • Phone: 781-391-8300
  • Fax:
Mailing address:
  • Phone: 781-647-4299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number19402
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: