MEDICARE: MR. DALE LAWRENCE PETRICH DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DE00004785	WA

General Provider Information

NPI Number	:	1407950595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DALE LAWRENCE PETRICH DDS

Provider Business Mailing Address
First Line	:	6720 FORT DENT WAY
Second Line	:	SUITE #210
City	:	TUKWILA
State	:	WA
Zip	:	98188
Country	:	US
Telephone Number	:	206-433-5595
Fax Number	:	206-433-0537

Provider Business Practice Location Address
First Line	:	6720 FORT DENT WAY
Second Line	:	SUITE #210
City	:	TUKWILA
State	:	WA
Zip	:	98188
Country	:	US
Telephone Number	:	206-433-5595
Fax Number	:	206-433-0537

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2006
Last Update Date	:	07/08/2007

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