1568655413 NPI number — JERRY L. PENNINGTON DDS

Table of content: JERRY L. PENNINGTON DDS (NPI 1568655413)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568655413 NPI number — JERRY L. PENNINGTON DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENNINGTON
Provider First Name:
JERRY
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568655413
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 337
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCARBRO
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25917-0337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-469-2905
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 SPY ROCK LOOP ROAD
Provider Second Line Business Practice Location Address:
LISA ELLIOTT HEALTH CENTER
Provider Business Practice Location Address City Name:
LOOKOUT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25868-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-574-2076
Provider Business Practice Location Address Fax Number:
304-574-1068
Provider Enumeration Date:
08/23/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  2641 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3810009746 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".