Provider Demographics
NPI:1033210380
Name:NICHOLAS JAMES PENNA D.D.S.,P.A.
Entity Type:Organization
Organization Name:NICHOLAS JAMES PENNA D.D.S.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:PENNA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-633-5942
Mailing Address - Street 1:1819 BRENNER AVE
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-2519
Mailing Address - Country:US
Mailing Address - Phone:704-633-5942
Mailing Address - Fax:704-639-0237
Practice Address - Street 1:1819 BRENNER AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2519
Practice Address - Country:US
Practice Address - Phone:704-633-5942
Practice Address - Fax:704-639-0237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC49361223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8996806Medicaid
NC899019PMedicaid