Provider Demographics
NPI:1598125395
Name:PENA, ALBA M
Entity Type:Individual
Prefix:DR
First Name:ALBA
Middle Name:M
Last Name:PENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALBA
Other - Middle Name:
Other - Last Name:CRESPO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:420 N ALEXANDER ST
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-4306
Mailing Address - Country:US
Mailing Address - Phone:813-752-5520
Mailing Address - Fax:940-766-6504
Practice Address - Street 1:420 N ALEXANDER ST
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-4306
Practice Address - Country:US
Practice Address - Phone:813-752-5520
Practice Address - Fax:940-766-6504
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-07
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31709122300000X
FLDN23824122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX31709OtherSTATE LICENSE