Provider Demographics
NPI:1073801700
Name:MCDONALD-PENA, TRACEY
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:MCDONALD-PENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 FULTON ST
Mailing Address - Street 2:BROOKLYN
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-2607
Mailing Address - Country:US
Mailing Address - Phone:718-636-4500
Mailing Address - Fax:718-636-2998
Practice Address - Street 1:1413 FULTON ST
Practice Address - Street 2:BROOKLYN
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-2607
Practice Address - Country:US
Practice Address - Phone:718-636-4500
Practice Address - Fax:718-636-2998
Is Sole Proprietor?:No
Enumeration Date:2011-07-15
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018252124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist