Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 08898 | NJ |
NPI | 1093763724 |
---|---|
Provider Name | Dr. Victor M. Petriella |
First Address | South Orange, NJ 07079-2264 |
Second Address | South Orange, NJ 07079-2264 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/05/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U11908 | (02) |