Provider Demographics
NPI:1063722601
Name:PERCIVAL, DAVID ALLEN (DMD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ALLEN
Last Name:PERCIVAL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-5321
Mailing Address - Country:US
Mailing Address - Phone:860-889-5166
Mailing Address - Fax:860-887-8254
Practice Address - Street 1:514 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-5321
Practice Address - Country:US
Practice Address - Phone:860-889-5166
Practice Address - Fax:860-887-8254
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT74541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice