Healthcare Provider Details

I. General information

NPI: 1235396904
Provider Name (Legal Business Name): STEVEN EUGENE PENN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1791 OAK AVE SUITE B
DAVIS CA
95616-1073
US

IV. Provider business mailing address

1791 OAK AVE SUITE B
DAVIS CA
95616-1073
US

V. Phone/Fax

Practice location:
  • Phone: 530-753-4530
  • Fax: 530-753-3263
Mailing address:
  • Phone: 530-753-4530
  • Fax: 530-753-3263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number29418
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: