Provider Demographics
NPI:1710328141
Name:DE PENA, LAURA M (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:M
Last Name:DE PENA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16919 N BAY RD
Mailing Address - Street 2:APT. 509
Mailing Address - City:SUNNY ISLES BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-4253
Mailing Address - Country:US
Mailing Address - Phone:561-506-8692
Mailing Address - Fax:
Practice Address - Street 1:16919 N BAY RD
Practice Address - Street 2:#509
Practice Address - City:SUNNY ISLES BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160-4253
Practice Address - Country:US
Practice Address - Phone:561-506-8692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-14
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN202441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice