Provider Demographics
NPI:1730893223
Name:PENA MORENO, BERENICE (RDH)
Entity type:Individual
Prefix:
First Name:BERENICE
Middle Name:
Last Name:PENA MORENO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19969 GREENLEY RD STE CANDD
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5908
Mailing Address - Country:US
Mailing Address - Phone:209-532-0034
Mailing Address - Fax:
Practice Address - Street 1:535 BODEGA CT
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-0714
Practice Address - Country:US
Practice Address - Phone:209-928-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34551124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1124286885OtherORGANIZATION