Provider Demographics
NPI:1386431310
Name:PENBERTHY, JEREMIAH DAVID (DMD)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:DAVID
Last Name:PENBERTHY
Suffix:
Gender:
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 W AVERY ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-4910
Mailing Address - Country:US
Mailing Address - Phone:208-771-1172
Mailing Address - Fax:
Practice Address - Street 1:3450 LACEY RD
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-5430
Practice Address - Country:US
Practice Address - Phone:630-743-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program