Provider Demographics
NPI:1801819685
Name:PENA, HECTOR (DMD)
Entity Type:Individual
Prefix:DR
First Name:HECTOR
Middle Name:
Last Name:PENA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1312 LITTLE NECK AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-1852
Mailing Address - Country:US
Mailing Address - Phone:917-674-0811
Mailing Address - Fax:
Practice Address - Street 1:3255 83RD ST
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11370-2007
Practice Address - Country:US
Practice Address - Phone:718-313-0613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0509121223G0001X, 1223X0400X
CT113431223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02420111Medicaid
NY9176251OtherDORAL USA DENTAL PROVIDER