Provider Demographics
NPI:1518760149
Name:PENA, THERESA MARIE (OMT)
Entity type:Individual
Prefix:MISS
First Name:THERESA
Middle Name:MARIE
Last Name:PENA
Suffix:
Gender:
Credentials:OMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 YERBA BUENA ST
Mailing Address - Street 2:
Mailing Address - City:MORRO BAY
Mailing Address - State:CA
Mailing Address - Zip Code:93442-2973
Mailing Address - Country:US
Mailing Address - Phone:805-540-9340
Mailing Address - Fax:
Practice Address - Street 1:8344 MORRO RD
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-3927
Practice Address - Country:US
Practice Address - Phone:805-242-2430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-29
Last Update Date:2025-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21606124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist