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General NPI Number Information
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NPI Number | 1497199830
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Entity Type | Organization
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Legal Business Name | CARLA D PENA DDS INC
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Dates
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Enumeration Date | 04/27/2013
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Last Update Date | 04/27/2013
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Provider Practice Location Address
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Address Line | 1401 W 11TH ST STE A
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City | TRACY
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State | CA
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Zip | 95376-3702
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Country | US
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Telephone | 209-830-7477
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Fax | 209-830-7977
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Provider Business Mailing Address
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Address Line | 1401 W 11TH ST STE A
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City | TRACY
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State | CA
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Zip | 95376-3702
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Country | US
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Telephone | 209-830-7477
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Fax | 209-830-7977
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Authorized Official
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Title or Position | PRESIDENT
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Name | CARLA D PENA
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Credential | DDS
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Telephone | 209-830-7477
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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 | 47774
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License Number State | CA
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