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General NPI Number Information
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NPI Number | 1174652135
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Entity Type | Individual
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Provider Name | FERNANDO DE LA PENA D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/05/2007
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Last Update Date | 09/09/2008
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Provider Practice Location Address
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Address Line | 2701 BEVERLY BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90057-1007
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Country | US
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Telephone | 213-389-6211
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Fax | 213-389-4168
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Provider Business Mailing Address
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Address Line | 3020 GLENMANOR PL
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City | LOS ANGELES
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State | CA
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Zip | 90039-1711
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Country | US
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Telephone | 323-660-8646
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Fax | 323-660-8646
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 43934
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License Number State | CA
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