Provider Demographics
NPI:1831101989
Name:PEZZULLO, DAVID ANTHONY (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ANTHONY
Last Name:PEZZULLO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 RESERVOIR AVE
Mailing Address - Street 2:SUITE 3E
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02907
Mailing Address - Country:US
Mailing Address - Phone:401-781-3393
Mailing Address - Fax:401-781-3408
Practice Address - Street 1:400 RESERVOIR AVE
Practice Address - Street 2:SUITE 3E
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907
Practice Address - Country:US
Practice Address - Phone:401-781-3393
Practice Address - Fax:401-781-3408
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN18511223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
DP12699Medicare UPIN