Provider Demographics
NPI:1568655413
Name:PENNINGTON, JERRY L (DDS)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:L
Last Name:PENNINGTON
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 1:497 MALL RD
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25901-6216
Mailing Address - Country:US
Mailing Address - Phone:304-469-2905
Mailing Address - Fax:
Practice Address - Street 1:497 MALL RD
Practice Address - Street 2:
Practice Address - City:OAK HILL
Practice Address - State:WV
Practice Address - Zip Code:25901-6216
Practice Address - Country:US
Practice Address - Phone:304-574-2076
Practice Address - Fax:304-574-1068
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2641122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810009746Medicaid
WV7405351Medicare PIN