Provider Demographics
NPI:1962014282
Name:PENA, GEOFFREY GLEN (DMD)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:GLEN
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 1:1401 W 11TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3702
Mailing Address - Country:US
Mailing Address - Phone:209-830-7477
Mailing Address - Fax:
Practice Address - Street 1:1401 W 11TH ST STE A
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3702
Practice Address - Country:US
Practice Address - Phone:209-830-7477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1052451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice