Provider Demographics
NPI:1922687326
Name:PENNYWELL, HAMILTON EVAN
Entity Type:Individual
Prefix:
First Name:HAMILTON
Middle Name:EVAN
Last Name:PENNYWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2171 N HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-6215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2171 N HIGHWAY 77
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-6215
Practice Address - Country:US
Practice Address - Phone:972-351-9910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX397551223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program