Provider Demographics
NPI:1255401030
Name:PENNINGTON, VERNON CHARLES (DDS)
Entity type:Individual
Prefix:DR
First Name:VERNON
Middle Name:CHARLES
Last Name:PENNINGTON
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 1:1571 STATELINE
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:38671
Mailing Address - Country:US
Mailing Address - Phone:662-342-0467
Mailing Address - Fax:662-342-0468
Practice Address - Street 1:1571 STATELINE
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MI
Practice Address - Zip Code:38671
Practice Address - Country:US
Practice Address - Phone:662-342-0467
Practice Address - Fax:662-342-0468
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS219585122300000X
TNDS0000004349122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist