MEDICARE: DR. MICHAEL ANTHONY PETRUZILLO 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	1223G0001X	General Practice Dentistry	023698	NY

General Provider Information

NPI Number	:	1891895132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL ANTHONY PETRUZILLO DDS

Provider Business Mailing Address
First Line	:	24 WOODLAND WAY
Second Line	:
City	:	MANHASSOT
State	:	NY
Zip	:	11030
Country	:	US
Telephone Number	:	718-672-3632
Fax Number	:

Provider Business Practice Location Address
First Line	:	7815 24TH AVE
Second Line	:
City	:	JACKSON HEIGHTS
State	:	NY
Zip	:	11370
Country	:	US
Telephone Number	:	718-672-3632
Fax Number	:

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

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	07/08/2007

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