Healthcare Provider Details

I. General information

NPI: 1619091154
Provider Name (Legal Business Name): WEN-HONG FELIX PENG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 05/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 W GARDENA BLVD
GARDENA CA
90247-4727
US

IV. Provider business mailing address

11301 W OLYMPIC BLVD # 702
LOS ANGELES CA
90064-1653
US

V. Phone/Fax

Practice location:
  • Phone: 310-323-0689
  • Fax: 310-323-0108
Mailing address:
  • Phone: 310-308-3204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number46124
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: