Provider Demographics
NPI:1952490047
Name:PELLEGRINO, JASON ANTHONY (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:ANTHONY
Last Name:PELLEGRINO
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 1:5920 HAMILTON BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WESCOSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18106-8942
Mailing Address - Country:US
Mailing Address - Phone:610-530-7901
Mailing Address - Fax:610-530-7905
Practice Address - Street 1:5920 HAMILTON BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:WESCOSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18106-8942
Practice Address - Country:US
Practice Address - Phone:610-530-7901
Practice Address - Fax:610-530-7905
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS031460L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice