Healthcare Provider Details

I. General information

NPI: 1417144387
Provider Name (Legal Business Name): MYRON T PENG DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7105 SW HAMPTON ST
TIGARD OR
97223-8314
US

IV. Provider business mailing address

PO BOX 338
GRAND RONDE OR
97347-0338
US

V. Phone/Fax

Practice location:
  • Phone: 800-813-2000
  • Fax:
Mailing address:
  • Phone: 503-879-2236
  • Fax: 503-879-5089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD8970
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: