Healthcare Provider Details

I. General information

NPI: 1518406164
Provider Name (Legal Business Name): STAMATINA PETRAKIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2017
Last Update Date: 09/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4102 28TH AVE
ASTORIA NY
11103
US

IV. Provider business mailing address

4102 28TH AVE
ASTORIA NY
11103-2977
US

V. Phone/Fax

Practice location:
  • Phone: 718-726-6291
  • Fax:
Mailing address:
  • Phone: 718-726-6291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number060366
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: