Provider Demographics
NPI:1336520329
Name:PETROVICH, CLARINA P (RDH)
Entity type:Individual
Prefix:MRS
First Name:CLARINA
Middle Name:P
Last Name:PETROVICH
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23205 BAY OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80138-5742
Mailing Address - Country:US
Mailing Address - Phone:808-352-9132
Mailing Address - Fax:
Practice Address - Street 1:23205 BAY OAKS AVE
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80138-5742
Practice Address - Country:US
Practice Address - Phone:808-352-9132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-15
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
124Q00000X
HI1696124Q00000X
VA0402203045124Q00000X
CODH.002025196124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist