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NPI Code Detail

MEDICARE: GUSTAVO PENA-VELASCO D.D.S., M.S.

MEDICARE: GUSTAVO PENA-VELASCO D.D.S., M.S.
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
11223S0112XOral and Maxillofacial Surgery (Dentist)D10925MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1851346639
Entity Type Code : Individual
Provider Name (Legal Business Name) : GUSTAVO PENA-VELASCO D.D.S., M.S.
Provider Business Mailing Address
First Line : 3950 VETERANS DR
Second Line : SUITE 100
City : SAINT CLOUD
State : MN
Zip : 56303-3410
Country : US
Telephone Number : 320-252-3611
Fax Number : 320-252-7574
Provider Business Practice Location Address
First Line : 3950 VETERANS DR
Second Line : SUITE 100
City : SAINT CLOUD
State : MN
Zip : 56303-3410
Country : US
Telephone Number : 320-252-3611
Fax Number : 320-252-7574
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/23/2006
Last Update Date : 03/14/2011

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Directions to “ GUSTAVO PENA-VELASCO D.D.S., M.S.” Practice Location

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