Provider Demographics
NPI:1417114505
Name:PENNELLA, SAMUEL C (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:C
Last Name:PENNELLA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 BELLEVUE AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-2430
Mailing Address - Country:US
Mailing Address - Phone:973-744-8004
Mailing Address - Fax:
Practice Address - Street 1:76 BELLEVUE AVE
Practice Address - Street 2:
Practice Address - City:UPPER MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07043-2430
Practice Address - Country:US
Practice Address - Phone:973-744-8004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-17
Last Update Date:2008-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ09713122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist