Provider Demographics
NPI:1801816384
Name:PEN, OLEG (DDS)
Entity Type:Individual
Prefix:
First Name:OLEG
Middle Name:
Last Name:PEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 AVENUE Z
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-3809
Mailing Address - Country:US
Mailing Address - Phone:718-648-4990
Mailing Address - Fax:718-648-4782
Practice Address - Street 1:1601 AVENUE Z
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3809
Practice Address - Country:US
Practice Address - Phone:718-648-4990
Practice Address - Fax:718-648-4782
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044465122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01384394Medicaid