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General NPI Number Information
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NPI Number | 1750069704
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Entity Type | Individual
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Provider Name | DOMINIQUE PETRONE DMD
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Gender | Female
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Dates
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Enumeration Date | 07/10/2023
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Last Update Date | 07/10/2023
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Provider Practice Location Address
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Address Line | 10670 SW TRADITION PKWY
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34987-2862
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Country | US
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Telephone | 772-345-8332
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Fax |
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Provider Business Mailing Address
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Address Line | 10280 SW STEPHANIE WAY UNIT 8201
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34987-1962
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Country | US
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Telephone | 570-401-5478
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Fax |
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 28243
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License Number State | FL
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