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General NPI Number Information
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NPI Number | 1063571974
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Entity Type | Individual
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Provider Name | PAUL S PETRUNGARO DDS, MS
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Gender | Male
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Dates
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Enumeration Date | 12/06/2006
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Last Update Date | 02/08/2018
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Provider Practice Location Address
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Address Line | 330 W FRONTAGE RD FL 2B
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City | NORTHFIELD
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State | IL
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Zip | 60093-3467
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Country | US
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Telephone | 847-386-6351
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Fax | 847-386-7169
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Provider Business Mailing Address
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Address Line | 330 W FRONTAGE RD FL 2B
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City | NORTHFIELD
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State | IL
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Zip | 60093-3467
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Country | US
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Telephone | 847-386-6351
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Fax | 847-386-7169
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 021.001401
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.020118
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License Number State | IL
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