MEDICARE: DR. CONG PENG DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	34144	TX
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	34144	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	34144	OTHER	TX	DENTAL LICENSE

General Provider Information

NPI Number	:	1750875662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CONG PENG DMD

Provider Business Mailing Address
First Line	:	3433 COVE VIEW BLVD APT 3533
Second Line	:
City	:	GALVESTON
State	:	TX
Zip	:	77554-8175
Country	:	US
Telephone Number	:	781-627-6588
Fax Number	:

Provider Business Practice Location Address
First Line	:	6821 STEWART RD
Second Line	:
City	:	GALVESTON
State	:	TX
Zip	:	77551-1841
Country	:	US
Telephone Number	:	781-627-6588
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2018
Last Update Date	:	04/14/2023

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