Provider Demographics
NPI:1174652135
Name:DE LA PENA, FERNANDO (DMD)
Entity Type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:
Last Name:DE LA PENA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 GLENMANOR PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-1711
Mailing Address - Country:US
Mailing Address - Phone:323-660-8646
Mailing Address - Fax:323-660-8646
Practice Address - Street 1:2701 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-1007
Practice Address - Country:US
Practice Address - Phone:213-389-6211
Practice Address - Fax:213-389-4168
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA439341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB43934-01OtherDENTI-CAL PROVIDER NO.