Provider Demographics
NPI:1225738909
Name:PENA DE OVALLES, MAYERLING
Entity Type:Individual
Prefix:
First Name:MAYERLING
Middle Name:
Last Name:PENA DE OVALLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MAYERLING
Other - Middle Name:
Other - Last Name:PENA ANGELES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3020 COSTA CLUB DR
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-5048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3020 COSTA CLUB DR
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-5048
Practice Address - Country:US
Practice Address - Phone:407-782-7407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL285941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program