Individual
GUSTAVO PENA-VELASCO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.D.S., M.S.
Contact information
Practice address
3950 VETERANS DR, SUITE 100, SAINT CLOUD, MN 56303-3410
(320) 252-3611
(320) 252-7574
Mailing address
3950 VETERANS DR, SUITE 100, SAINT CLOUD, MN 56303-3410
(320) 252-3611
(320) 252-7574
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
D10925
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
976017200
—
MN
Enumeration date
05/23/2006
Last updated
03/14/2011
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