Provider Demographics
NPI:1518715911
Name:PENALOZA GUEVARA, JOSE LUIS (DMD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:LUIS
Last Name:PENALOZA GUEVARA
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 1:3755 COLLINGWOOD LN
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-9340
Mailing Address - Country:US
Mailing Address - Phone:864-376-8428
Mailing Address - Fax:
Practice Address - Street 1:1645 E HWY 50 STE 100
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-5199
Practice Address - Country:US
Practice Address - Phone:352-327-8957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN28900122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist