Provider Demographics
NPI:1205985553
Name:JENGO, PETER (DDS)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:JENGO
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 1:326 NICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420
Mailing Address - Country:US
Mailing Address - Phone:978-878-8516
Mailing Address - Fax:978-878-8418
Practice Address - Street 1:175 CONNORS STREET
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440
Practice Address - Country:US
Practice Address - Phone:978-410-6100
Practice Address - Fax:978-410-6176
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10648122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0212270Medicaid