Provider Demographics
NPI:1194351718
Name:PENG, EUGENE
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:PENG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11435 TIARA ST APT 5
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-1137
Mailing Address - Country:US
Mailing Address - Phone:617-894-9588
Mailing Address - Fax:
Practice Address - Street 1:270 26TH ST STE 301
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90402-2567
Practice Address - Country:US
Practice Address - Phone:310-394-2796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1066191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty