Provider Demographics
NPI:1992037782
Name:PENESIS, VINCE A (DDS)
Entity Type:Individual
Prefix:DR
First Name:VINCE
Middle Name:A
Last Name:PENESIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 OAKBROOK CTR
Mailing Address - Street 2:#714
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1806
Mailing Address - Country:US
Mailing Address - Phone:630-654-3331
Mailing Address - Fax:630-954-2910
Practice Address - Street 1:120 OAKBROOK CTR
Practice Address - Street 2:#714
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1806
Practice Address - Country:US
Practice Address - Phone:630-654-3331
Practice Address - Fax:630-954-2910
Is Sole Proprietor?:No
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190258971223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics