Healthcare Provider Details

I. General information

NPI: 1609239557
Provider Name (Legal Business Name): CHRISTINA PENN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2016
Last Update Date: 08/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 2ND ST STE B
BRENTWOOD CA
94513-2223
US

IV. Provider business mailing address

1140 2ND ST STE B
BRENTWOOD CA
94513-2223
US

V. Phone/Fax

Practice location:
  • Phone: 925-240-8111
  • Fax:
Mailing address:
  • Phone: 925-240-8111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDDS103903
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: