Active NPI
Teodoro David Pena
- Dentist
- Chula Vista, CA
National Provider Identifier
1104332741
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 64509
- Practice address
- 510 Broadway Ste 4-5
Chula Vista, CA 91910 - Phone
- (619) 476-9400
- NPI assigned
- Dec 19, 2017
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 64509 | CA | Primary |
Addresses
Primary practice location
510 Broadway Ste 4-5
Chula Vista, CA 91910
Mailing address
510 Broadway Ste 4-5
Chula Vista, CA 91910-5306
Phone (619) 476-9400
Other practice location 1
1436 HIghland Ave.
National City, CA 91950
Phone (619) 474-7417
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20180625002499 | CA | Order and Referring Only - Dentist | 1759636236 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 64509 | CA | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1513641600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1528070400000",
"number": "1104332741",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "510 BROADWAY STE 4-5",
"city": "CHULA VISTA",
"state": "CA",
"postal_code": "919105306",
"telephone_number": "619-476-9400"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "510 BROADWAY STE 4-5",
"city": "CHULA VISTA",
"state": "CA",
"postal_code": "91910",
"telephone_number": "619-476-9400"
}
],
"practiceLocations": [
{
"address_1": "1436 HIghland Ave.",
"address_purpose": "LOCATION",
"city": "National City",
"state": "CA",
"postal_code": "91950",
"country_code": "US",
"telephone_number": "619-474-7417",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "PENA",
"first_name": "TEODORO",
"middle_name": "DAVID",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2017-12-19",
"last_updated": "2018-06-04",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "CA",
"license": "64509",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Chula Vista, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 4, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.