Provider Demographics
NPI:1356024533
Name:PENA, GUADALUPE DEL ROSA CHAVEZ
Entity type:Individual
Prefix:
First Name:GUADALUPE DEL ROSA
Middle Name:CHAVEZ
Last Name:PENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3609 W 15TH LN
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-4155
Mailing Address - Country:US
Mailing Address - Phone:928-975-4295
Mailing Address - Fax:
Practice Address - Street 1:AV. REVOLUCION Y CALLE 17 NUM797 COL. RESDIDENCIAS
Practice Address - Street 2:
Practice Address - City:SAN LUIS RIO COLORADO
Practice Address - State:SONORA
Practice Address - Zip Code:83450
Practice Address - Country:MX
Practice Address - Phone:653-536-1567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5166749122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist