Provider Demographics
NPI:1689737496
Name:PENNA, NICHOLAS JAMES (DDS,PA)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JAMES
Last Name:PENNA
Suffix:
Gender:M
Credentials:DDS,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 BRENNER AVE
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-2519
Mailing Address - Country:US
Mailing Address - Phone:704-633-5942
Mailing Address - Fax:704-639-0237
Practice Address - Street 1:1819 BRENNER AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2519
Practice Address - Country:US
Practice Address - Phone:704-633-5942
Practice Address - Fax:704-639-0237
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC49361223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8996806Medicaid
NC899019PMedicaid