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General NPI Number Information
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NPI Number | 1134414154
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Entity Type | Organization
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Legal Business Name | PETITO ORAL SURGERY
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Dates
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Enumeration Date | 06/17/2011
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Last Update Date | 06/17/2011
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Provider Practice Location Address
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Address Line | 400 MASSASOIT AVE SUITE 103
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City | EAST PROVIDENCE
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State | RI
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Zip | 02914-2012
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Country | US
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Telephone | 401-578-1866
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Fax | 508-336-6580
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Provider Business Mailing Address
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Address Line | 400 MASSASOIT AVE SUITE 103
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City | EAST PROVIDENCE
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State | RI
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Zip | 02914-2012
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Country | US
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Telephone | 401-578-1866
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Fax | 508-336-6580
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Authorized Official
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Title or Position | OWNER
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Name | DR. ANTHONY ROCCO PETITO
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Credential | DDS MD
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Telephone | 401-578-1688
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 2552
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License Number State | RI
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