Provider Demographics
NPI:1356902068
Name:PALERMO, ANDREW J
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:PALERMO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 PLEASANT ST STE 102-103
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02723-1000
Mailing Address - Country:US
Mailing Address - Phone:508-673-3044
Mailing Address - Fax:508-673-4396
Practice Address - Street 1:933 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02723-1000
Practice Address - Country:US
Practice Address - Phone:774-301-8428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-24
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060378122300000X
MADN18584271223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY060378OtherAPPLICATION PENDING
NY060378OtherNEW PROVIDER APPLICATION BEING SUBMITTED