Provider Demographics
NPI:1720374838
Name:WILLIAM A. PENA DMD, PA
Entity Type:Organization
Organization Name:WILLIAM A. PENA DMD, PA
Other - Org Name:AMERICAN PEDIATRIC DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS, MBA
Authorized Official - Phone:415-216-6649
Mailing Address - Street 1:10021 PINES BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6191
Mailing Address - Country:US
Mailing Address - Phone:954-417-1337
Mailing Address - Fax:954-417-1338
Practice Address - Street 1:10021 PINES BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6191
Practice Address - Country:US
Practice Address - Phone:954-417-1337
Practice Address - Fax:954-417-1338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN176081223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000641100Medicaid