| Entity Name: | WILLIAM A. PENA, DMD, PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 16 Sep 2009 (15 years ago) |
| Document Number: | P09000078671 |
| FEI/EIN Number | NOT APPLICABLE |
| Address: | 2970 Brandywine Road, Suite 200, Atlanta, GA, 30341, US |
| Mail Address: | 2970 Brandywine Road, Suite 200, Atlanta, GA, 30341, US |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1720374838 | 2011-06-27 | 2011-06-27 | 10021 PINES BLVD, SUITE 100, PEMBROKE PINES, FL, 330246191, US | 10021 PINES BLVD, SUITE 100, PEMBROKE PINES, FL, 330246191, US | |||||||||||||||||||||||||
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| Phone | +1 954-417-1337 |
| Fax | 9544171338 |
Authorized person
| Name | DR. WILLIAM ANTONIO PENA |
| Role | OWNER/PRESIDENT |
| Phone | 4152166649 |
Taxonomy
| Taxonomy Code | 1223P0221X - Pediatric Dentist |
| License Number | DN17608 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 000641100 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| CT CORPORATION SYSTEM | Agent | 1200 SOUTH PINE ISLAND ROAD, PLANTATION, FL, 33324 |
| Name | Role | Address |
|---|---|---|
| Santiago Gerardo | Auth | 2970 Brandywine Road, Atlanta, GA, 30341 |
| Name | Role | Address |
|---|---|---|
| Santiago Gerardo | President | 2970 Brandywine Road, Atlanta, GA, 30341 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G11000075614 | AMERICAN PEDIATRIC DENTAL GROUP | ACTIVE | 2011-07-29 | 2026-12-31 | No data | 10021 PINES BLVD., SUITE #100, PEMBROKE PINES, FL, 33024 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-04-05 | 2970 Brandywine Road, Suite 200, Atlanta, GA 30341 | No data |
| CHANGE OF MAILING ADDRESS | 2024-04-05 | 2970 Brandywine Road, Suite 200, Atlanta, GA 30341 | No data |
| REGISTERED AGENT NAME CHANGED | 2021-09-14 | CT CORPORATION SYSTEM | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2021-09-14 | 1200 SOUTH PINE ISLAND ROAD, PLANTATION, FL 33324 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-05 |
| ANNUAL REPORT | 2023-02-23 |
| ANNUAL REPORT | 2022-03-24 |
| Reg. Agent Change | 2021-09-14 |
| ANNUAL REPORT | 2021-04-25 |
| ANNUAL REPORT | 2020-06-25 |
| ANNUAL REPORT | 2019-04-03 |
| ANNUAL REPORT | 2018-03-08 |
| ANNUAL REPORT | 2017-02-02 |
| ANNUAL REPORT | 2016-01-25 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
