MEDICARE: DR. CARLOS EDUARDO DE LA PENA D.D.S., P.C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D18633	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	742787735	OTHER	TX	TAX ID #
2	D18633	OTHER	TX	DENTAL LICEINCE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265519805
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARLOS EDUARDO DE LA PENA D.D.S., P.C

Provider Business Mailing Address
First Line	:	PO BOX 618
Second Line	:	2230 VETERANS BLVD STE 200
City	:	EAGLE PASS
State	:	TX
Zip	:	78853-0618
Country	:	US
Telephone Number	:	830-773-0707
Fax Number	:	830-757-4550

Provider Business Practice Location Address
First Line	:	2230 N VETERANS BLVD
Second Line	:	SUITE 200
City	:	EAGLE PASS
State	:	TX
Zip	:	78852-6619
Country	:	US
Telephone Number	:	830-773-0707
Fax Number	:	830-757-4550

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/09/2007

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Directions to “ DR. CARLOS EDUARDO DE LA PENA D.D.S., P.C” Practice Location

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