Provider Demographics
NPI:1912190307
Name:CARNICELLI, PETER D (DMD)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:D
Last Name:CARNICELLI
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 1:185 HERMON ST
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:MA
Mailing Address - Zip Code:02152-3024
Mailing Address - Country:US
Mailing Address - Phone:617-846-1280
Mailing Address - Fax:617-846-5691
Practice Address - Street 1:185 HERMON ST
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:MA
Practice Address - Zip Code:02152-3024
Practice Address - Country:US
Practice Address - Phone:617-846-1280
Practice Address - Fax:617-846-5691
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA123511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice