Basic Information
| Provider Information | |||||||||
| NPI: | 1205325966 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENATE | ||||||||
| FirstName: | GLORIA | ||||||||
| MiddleName: | JUDITH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | I | ||||||||
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| Mailing Information | |||||||||
| Address1: | MADIGAN ANNEX 9900 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539684944 | ||||||||
| FaxNumber: | 2539684900 | ||||||||
| Practice Location | |||||||||
| Address1: | 2103 NORTH DIVISION STREET | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539673416 | ||||||||
| FaxNumber: | 2539667848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2018 | ||||||||
| LastUpdateDate: | 05/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 22724 | FL | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 22724 | 01 | FL | DEPARTMENT OF HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE | OTHER |