Healthcare Provider Details

I. General information

NPI: 1851551683
Provider Name (Legal Business Name): PETER D CARNICELLI DMD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 HERMON ST
WINTHROP MA
02152-3024
US

IV. Provider business mailing address

185 HERMON ST
WINTHROP MA
02152-3024
US

V. Phone/Fax

Practice location:
  • Phone: 617-846-1280
  • Fax: 617-846-5691
Mailing address:
  • Phone: 617-846-1280
  • Fax: 617-846-5691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12351
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number12351
License Number StateMA

VIII. Authorized Official

Name: MR. PETER D CARNICELLI
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 617-846-1280