Provider Demographics
NPI:1609974815
Name:PANUCCI, DONNA L (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:L
Last Name:PANUCCI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-1417
Mailing Address - Country:US
Mailing Address - Phone:304-744-6311
Mailing Address - Fax:304-744-8832
Practice Address - Street 1:133 7TH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1417
Practice Address - Country:US
Practice Address - Phone:304-744-6311
Practice Address - Fax:304-744-8832
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV31741223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0137687000Medicaid