=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265248546
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PENNA ORTHODONTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2024
-----------------------------------------------------
Last Update Date | 12/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2710 CENTERVILLE RD STE 215
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19808-1664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-998-8783
-----------------------------------------------------
Fax | 302-998-8786
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2710 CENTERVILLE RD STE 215
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19808-1664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-998-8783
-----------------------------------------------------
Fax | 302-998-8786
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROBERT PENNA
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 302-998-8783
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------