Provider Demographics
NPI:1629641907
Name:PENTA, ALEXANDRA (DMD)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:PENTA
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 1:899 CONGRESS ST APT 602
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02210-2818
Mailing Address - Country:US
Mailing Address - Phone:617-347-0349
Mailing Address - Fax:
Practice Address - Street 1:102 SHORE DR STE 302
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3154
Practice Address - Country:US
Practice Address - Phone:508-854-9994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0434821223G0001X
PA390200000X
MADN18597651223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program