Provider Demographics
NPI:1831251727
Name:PECUCH, NICHOLAS E (DDS)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:E
Last Name:PECUCH
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 1:165 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518
Mailing Address - Country:US
Mailing Address - Phone:570-457-3131
Mailing Address - Fax:570-457-3131
Practice Address - Street 1:165 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OLD FORGE
Practice Address - State:PA
Practice Address - Zip Code:18518
Practice Address - Country:US
Practice Address - Phone:570-457-3131
Practice Address - Fax:570-457-3131
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS016790L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist