Provider Demographics
NPI:1063434983
Name:PETRIE, SCOTT FRASER (DMD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:FRASER
Last Name:PETRIE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 GRACE DR
Mailing Address - Street 2:
Mailing Address - City:MEDFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02052-2819
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1428 MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081
Practice Address - Country:US
Practice Address - Phone:508-668-8008
Practice Address - Fax:508-668-8808
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA166011223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000708OtherDELTA
MAX10973OtherBCBS