Healthcare Provider Details

I. General information

NPI: 1912190307
Provider Name (Legal Business Name): PETER D CARNICELLI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 08/20/2007
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 TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12351
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: