Provider Demographics
NPI:1871159665
Name:PETRY BAUTISTA, PRISCILA FABIANA (DDS)
Entity type:Individual
Prefix:DR
First Name:PRISCILA FABIANA
Middle Name:
Last Name:PETRY BAUTISTA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11777 S AUTUMN RIDGE CV
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-7345
Mailing Address - Country:US
Mailing Address - Phone:954-397-4102
Mailing Address - Fax:
Practice Address - Street 1:168 E 5900 S STE C103
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7262
Practice Address - Country:US
Practice Address - Phone:801-875-0370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-16
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT12448109-9923122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program