Provider Demographics
NPI:1184886244
Name:PETROSINO, ANTONIA (DDS)
Entity type:Individual
Prefix:
First Name:ANTONIA
Middle Name:
Last Name:PETROSINO
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 1:818 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-3726
Mailing Address - Country:US
Mailing Address - Phone:708-450-1170
Mailing Address - Fax:708-450-0008
Practice Address - Street 1:818 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-3726
Practice Address - Country:US
Practice Address - Phone:708-450-1170
Practice Address - Fax:708-450-0008
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-0260361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice