Provider Demographics
NPI:1700229168
Name:PERGIOVANNI, MARY LESLIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LESLIE
Last Name:PERGIOVANNI
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 1:825 CROMWELL AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-3013
Mailing Address - Country:US
Mailing Address - Phone:860-721-9002
Mailing Address - Fax:860-721-9048
Practice Address - Street 1:825 CROMWELL AVE
Practice Address - Street 2:SUITE F
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-3013
Practice Address - Country:US
Practice Address - Phone:860-721-9002
Practice Address - Fax:860-721-9048
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT64071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice