Provider Demographics
NPI:1306190095
Name:REBECCA IRENE A PENA D M D A DENTAL
Entity Type:Organization
Organization Name:REBECCA IRENE A PENA D M D A DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA IRENE
Authorized Official - Middle Name:ALCAZAREN
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:562-920-1726
Mailing Address - Street 1:5445 DEL AMO BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-2760
Mailing Address - Country:US
Mailing Address - Phone:562-920-1726
Mailing Address - Fax:562-920-1728
Practice Address - Street 1:5445 DEL AMO BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-2760
Practice Address - Country:US
Practice Address - Phone:562-920-1726
Practice Address - Fax:562-920-1728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1457368425OtherNPI TYPE 1
CA49181OtherDENTAL LICENSE
DCBP7648009OtherDRUG ENFORCEMENT ADMINISTRATION