Provider Demographics
NPI:1528277217
Name:MARK M. PETRYNA,D.D.S.,PA
Entity type:Organization
Organization Name:MARK M. PETRYNA,D.D.S.,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:MARIAN
Authorized Official - Last Name:PETRYNA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-847-7799
Mailing Address - Street 1:1348 MATTHEWS TOWNSHIP PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-4929
Mailing Address - Country:US
Mailing Address - Phone:704-847-7799
Mailing Address - Fax:704-849-7925
Practice Address - Street 1:1348 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-4929
Practice Address - Country:US
Practice Address - Phone:704-847-7799
Practice Address - Fax:704-849-7925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC60751223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9705AOtherBCBS OF NC
NC476352OtherUNITED CONCORDIA
NCU20457Medicare UPIN