Healthcare Provider Details

I. General information

NPI: 1265549091
Provider Name (Legal Business Name): THOMAS G DEPETRILLO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 ANGELL ST
PROVIDENCE RI
02906-4403
US

IV. Provider business mailing address

425 ANGELL ST
PROVIDENCE RI
02906-4403
US

V. Phone/Fax

Practice location:
  • Phone: 401-272-2331
  • Fax:
Mailing address:
  • Phone: 401-272-2331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2360
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: