Healthcare Provider Details

I. General information

NPI: 1104332741
Provider Name (Legal Business Name): TEODORO DAVID PENA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2017
Last Update Date: 06/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 BROADWAY STE 4-5
CHULA VISTA CA
91910
US

IV. Provider business mailing address

510 BROADWAY STE 4-5
CHULA VISTA CA
91910-5306
US

V. Phone/Fax

Practice location:
  • Phone: 619-476-9400
  • Fax:
Mailing address:
  • Phone: 619-476-9400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number64509
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: