Provider Demographics
NPI:1063571974
Name:PETRUNGARO, PAUL S (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:S
Last Name:PETRUNGARO
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 W FRONTAGE RD FL 2B
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-3467
Mailing Address - Country:US
Mailing Address - Phone:847-386-6351
Mailing Address - Fax:847-386-7169
Practice Address - Street 1:330 W FRONTAGE RD FL 2B
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3467
Practice Address - Country:US
Practice Address - Phone:847-386-6351
Practice Address - Fax:847-386-7169
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.0014011223P0300X
IL019.020118122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND11084OtherSTATE DENTAL LICENSE