Provider Demographics
NPI:1316908569
Name:PERACCHIO, PAUL C (DMD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:C
Last Name:PERACCHIO
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 1:31 HANOVER FARMS RD
Mailing Address - Street 2:
Mailing Address - City:BOLTON
Mailing Address - State:CT
Mailing Address - Zip Code:06043-7647
Mailing Address - Country:US
Mailing Address - Phone:860-643-9229
Mailing Address - Fax:
Practice Address - Street 1:945 MAIN ST
Practice Address - Street 2:SUITE 310
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-6064
Practice Address - Country:US
Practice Address - Phone:860-647-9926
Practice Address - Fax:860-645-7723
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT77081223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP3603721OtherOXFORD
CT020007708CT01OtherANTHEM BLUE CROSS
CT762391OtherCONNECTICARE
CT2V5967OtherHEALTHNET
CTP3603721OtherOXFORD