Provider Demographics
NPI:1710493895
Name:PESILLO, KAREN S (PHDHP)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:S
Last Name:PESILLO
Suffix:
Gender:F
Credentials:PHDHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:566 COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-7065
Mailing Address - Country:US
Mailing Address - Phone:570-490-5745
Mailing Address - Fax:
Practice Address - Street 1:566 COUNTRY RD
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-7065
Practice Address - Country:US
Practice Address - Phone:412-255-4672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-27
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADH006260L124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA124Q00000XMedicaid