Provider Demographics
NPI:1104031335
Name:PENNISE, SAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:PENNISE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 MECHANIC STREET
Mailing Address - Street 2:BOX 386
Mailing Address - City:HAMMONDSPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14840-0386
Mailing Address - Country:US
Mailing Address - Phone:607-569-2242
Mailing Address - Fax:607-569-2278
Practice Address - Street 1:28 MECHANIC ST
Practice Address - Street 2:BOX 386
Practice Address - City:HAMMONDSPORT
Practice Address - State:NY
Practice Address - Zip Code:14840
Practice Address - Country:US
Practice Address - Phone:607-569-2242
Practice Address - Fax:607-569-2278
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0333601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice