Active NPI
Peter Jengo, D.D.S
- Dentist
- Gardner, MA
National Provider Identifier
1205985553
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 10648
- Practice address
- 175 Connors Street
Gardner, MA 01440 - Phone
- (978) 410-6100
- Fax
- (978) 410-6176
- NPI assigned
- Jan 9, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 10648 | MA | Primary |
Addresses
Primary practice location
175 Connors Street
Gardner, MA 01440
Mailing address
326 Nichols Rd
Fitchburg, MA 01420
Phone (978) 878-8516
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0212270 | Medicaid | MA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20161103000007 | MA | Order and Referring Only - Dentist | 5991083412 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 10648 | MA | MD | Massage Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1168300800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1439856000000",
"number": "1205985553",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "326 NICHOLS RD",
"city": "FITCHBURG",
"state": "MA",
"postal_code": "01420",
"telephone_number": "978-878-8516",
"fax_number": "978-878-8418"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "175 CONNORS STREET",
"city": "GARDNER",
"state": "MA",
"postal_code": "01440",
"telephone_number": "978-410-6100",
"fax_number": "978-410-6176"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JENGO",
"first_name": "PETER",
"name_prefix": "Dr.",
"credential": "D.D.S",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-01-09",
"last_updated": "2015-08-18",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "MA",
"license": "10648",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "0212270",
"state": "MA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Gardner, MA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 18, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.