Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 2441 | MT |
N | 1223E0200X | Endodontist | D12284 | MN |
NPI | 1033366075 |
---|---|
Provider Name | Dr. Joseph Anthony Petrino |
First Address | Missoula, MT 59802-3113 |
Second Address | Missoula, MT 59801-2117 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/08/2008 |
Last Update Date | 06/09/2011 |