Provider Demographics
NPI:1821138108
Name:PANDOLFO, JOSEPHINE C (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPHINE
Middle Name:C
Last Name:PANDOLFO
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 1:355 LOWELL ST
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-4000
Mailing Address - Country:US
Mailing Address - Phone:978-532-3316
Mailing Address - Fax:978-538-9569
Practice Address - Street 1:355 LOWELL ST
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-4000
Practice Address - Country:US
Practice Address - Phone:978-532-3316
Practice Address - Fax:978-538-9569
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA141881223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX04554OtherBC BS PROVIDER #