MEDICARE: TENA DENTAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	48389	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G93496-02	OTHER	CA	DENTICAL

General Provider Information

NPI Number	:	1194909002
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TENA DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	525 S AZUSA WAY
Second Line	:
City	:	LA PUENTE
State	:	CA
Zip	:	91744-5113
Country	:	US
Telephone Number	:	626-810-0045
Fax Number	:

Provider Business Practice Location Address
First Line	:	525 S AZUSA WAY
Second Line	:
City	:	LA PUENTE
State	:	CA
Zip	:	91744-5113
Country	:	US
Telephone Number	:	626-810-0045
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. ERNERSTO M TENA
Credential	:	DDS
Telephone Number	:	626-810-0045

Provider Enumeration Date	:	12/27/2007
Last Update Date	:	12/27/2007

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Directions to “TENA DENTAL CORPORATION ” Practice Location

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