Healthcare Provider Details

I. General information

NPI: 1316915788
Provider Name (Legal Business Name): DAVID M. PETRARCA, DDS & SUNGYON BANG, DMD, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 01/16/2020
Certification Date: 01/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 HIGH ST
MEDFORD MA
02155-3813
US

IV. Provider business mailing address

80 HIGH ST
MEDFORD MA
02155-3813
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateMA

VIII. Authorized Official

Name: DR. DAVID MICHAEL PETRARCA
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 781-391-8300