Provider Demographics
NPI:1265519805
Name:DE LA PENA, CARLOS EDUARDO (DDS, PC)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:EDUARDO
Last Name:DE LA PENA
Suffix:
Gender:M
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 618
Mailing Address - Street 2:2230 VETERANS BLVD STE 200
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78853-0618
Mailing Address - Country:US
Mailing Address - Phone:830-773-0707
Mailing Address - Fax:830-757-4550
Practice Address - Street 1:2230 N VETERANS BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-6619
Practice Address - Country:US
Practice Address - Phone:830-773-0707
Practice Address - Fax:830-757-4550
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD186331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX742787735OtherTAX ID #
TXD18633OtherDENTAL LICEINCE
TX009317101Medicaid