Provider Demographics
NPI:1083721690
Name:PENNACCHIO, EVELYN A (DMD)
Entity Type:Individual
Prefix:DR
First Name:EVELYN
Middle Name:A
Last Name:PENNACCHIO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151
Mailing Address - Country:US
Mailing Address - Phone:781-286-2800
Mailing Address - Fax:781-289-5959
Practice Address - Street 1:16 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151
Practice Address - Country:US
Practice Address - Phone:781-286-2800
Practice Address - Fax:781-289-5959
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA165401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX05936OtherBCBS
T57715Medicare UPIN