Healthcare Provider Details

I. General information

NPI: 1629103494
Provider Name (Legal Business Name): MARK M PETRYNA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1348 MATTHEWS TOWNSHIP PKWY SUITE 101
MATTHEWS NC
28105
US

IV. Provider business mailing address

1348 MATTHEWS TOWNSHIP PARKWAY SUITE 101
MATTHEWS NC
28105
US

V. Phone/Fax

Practice location:
  • Phone: 704-847-7799
  • Fax: 704-849-7925
Mailing address:
  • Phone: 704-847-7799
  • Fax: 704-849-7925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberNC6075
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: