Provider Demographics
NPI:1528118841
Name:DEPETRIS, ERIC R (DMD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:R
Last Name:DEPETRIS
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 1:2550 COUNTY ROAD 220
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-6532
Mailing Address - Country:US
Mailing Address - Phone:904-272-6600
Mailing Address - Fax:904-276-0550
Practice Address - Street 1:2550 COUNTY ROAD 220
Practice Address - Street 2:SUITE ONE
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-6532
Practice Address - Country:US
Practice Address - Phone:904-272-6600
Practice Address - Fax:904-276-0550
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN159601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice