Healthcare Provider Details

I. General information

NPI: 1881827780
Provider Name (Legal Business Name): PETRA DIAGNOSTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2009
Last Update Date: 08/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 KINGSTOWN RD SUITE 203
NARRAGANSETT RI
02882-3262
US

IV. Provider business mailing address

350 KINGSTOWN RD SUITE 203
NARRAGANSETT RI
02882-3262
US

V. Phone/Fax

Practice location:
  • Phone: 401-284-3500
  • Fax: 401-284-3502
Mailing address:
  • Phone: 401-284-3500
  • Fax: 401-284-3502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2494
License Number StateRI

VIII. Authorized Official

Name: LISA W. TYLER
Title or Position: PRESIDENT
Credential: DMD
Phone: 401-295-0260