Healthcare Provider Details

I. General information

NPI: 1548544117
Provider Name (Legal Business Name): WILLARD PENG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2011
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30520 RANCHO CALIFORNIA ROAD, SUITE A105
TEMECULA CA
92591-3282
US

IV. Provider business mailing address

30520 RANCHO CALIFORNIA ROAD, SUITE A105
TEMECULA CA
92591-3282
US

V. Phone/Fax

Practice location:
  • Phone: 951-694-0545
  • Fax: 951-694-5654
Mailing address:
  • Phone: 951-694-0545
  • Fax: 951-694-5654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number59666
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number59666
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: