Provider Demographics
NPI:1659466936
Name:PENNIALL, BRIAN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MICHAEL
Last Name:PENNIALL
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 1:40W330 LAFOX ROAD
Mailing Address - Street 2:SUITE C-1
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175
Mailing Address - Country:US
Mailing Address - Phone:630-444-1730
Mailing Address - Fax:630-444-1732
Practice Address - Street 1:40W330 LAFOX ROAD
Practice Address - Street 2:SUITE C-1
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175
Practice Address - Country:US
Practice Address - Phone:630-444-1730
Practice Address - Fax:630-444-1732
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist