Provider Demographics
NPI:1194890426
Name:PETROV, NELSON MARK (DDS)
Entity type:Individual
Prefix:
First Name:NELSON
Middle Name:MARK
Last Name:PETROV
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 NORTH ABBE RD STE C
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-1649
Mailing Address - Country:US
Mailing Address - Phone:440-366-5530
Mailing Address - Fax:440-366-5211
Practice Address - Street 1:1212 NORTH ABBE RD STE C
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-1649
Practice Address - Country:US
Practice Address - Phone:440-366-5530
Practice Address - Fax:440-366-5211
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH125371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice