Provider Demographics
NPI:1245360981
Name:DAMIANI, PERRY JOEL (DMD)
Entity type:Individual
Prefix:MR
First Name:PERRY
Middle Name:JOEL
Last Name:DAMIANI
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 1:16127 KASOTA RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CO
Mailing Address - Zip Code:92307
Mailing Address - Country:US
Mailing Address - Phone:760-946-2168
Mailing Address - Fax:760-946-4099
Practice Address - Street 1:16127 KASOTA RD
Practice Address - Street 2:SUITE 105
Practice Address - City:APPLE VALLEY
Practice Address - State:CO
Practice Address - Zip Code:92307
Practice Address - Country:US
Practice Address - Phone:760-946-2168
Practice Address - Fax:760-946-4099
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35197122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB3519701Medicaid
CAB3519701Medicaid
DS0351970Medicare ID - Type Unspecified