Healthcare Provider Details

I. General information

NPI: 1386080893
Provider Name (Legal Business Name): PETER WILLIAM INNACOLA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2013
Last Update Date: 06/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 LINCOLN HWY E CARANO DENTAL GRP
LANCASTER PA
17602-2663
US

IV. Provider business mailing address

1670 LINCOLN HWY E CARANO DENTAL GRP
LANCASTER PA
17602-2663
US

V. Phone/Fax

Practice location:
  • Phone: 717-394-1067
  • Fax:
Mailing address:
  • Phone: 717-394-1067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS040000
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: