Provider Demographics
NPI:1265324388
Name:PENDERGAST, PAYTON LEE (DT)
Entity type:Individual
Prefix:
First Name:PAYTON
Middle Name:LEE
Last Name:PENDERGAST
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 LILAC LN
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-1427
Mailing Address - Country:US
Mailing Address - Phone:507-514-8785
Mailing Address - Fax:
Practice Address - Street 1:309 HOLLY LN
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5422
Practice Address - Country:US
Practice Address - Phone:507-388-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-15
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT189125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist