Healthcare Provider Details

I. General information

NPI: 1992137533
Provider Name (Legal Business Name): NEIL GRANT PENAFLORIDA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2013
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2878 CAMPUS PKWY
RIVERSIDE CA
92507-0966
US

IV. Provider business mailing address

29560 RANCHO CALIFORNIA RD
TEMECULA CA
92591-5294
US

V. Phone/Fax

Practice location:
  • Phone: 951-571-0011
  • Fax: 951-571-0012
Mailing address:
  • Phone: 951-699-2144
  • Fax: 951-506-4040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number58441
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: