Provider Demographics
NPI:1043318421
Name:PETRICK, THOMAS P JR (DMD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:P
Last Name:PETRICK
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:157 GOOSE LANE
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2100
Mailing Address - Country:US
Mailing Address - Phone:203-453-4475
Mailing Address - Fax:203-453-3314
Practice Address - Street 1:157 GOOSE LANE
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2100
Practice Address - Country:US
Practice Address - Phone:203-453-4475
Practice Address - Fax:203-453-3314
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CTCT007691207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT007691OtherLICENSE NUMBER
BP1544495OtherFEDERAL DEA