Healthcare Provider Details

I. General information

NPI: 1437084852
Provider Name (Legal Business Name): NATHANIEL FASIKA PETROS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 3RD AVE
KINGSTON PA
18704-5810
US

IV. Provider business mailing address

122 WOODLAND DR
WHITE HAVEN PA
18661-2439
US

V. Phone/Fax

Practice location:
  • Phone: 570-288-5588
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: