Provider Demographics
NPI:1033778162
Name:SHI, PENG
Entity Type:Individual
Prefix:
First Name:PENG
Middle Name:
Last Name:SHI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WOODSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:DRESHER
Mailing Address - State:PA
Mailing Address - Zip Code:19025-1817
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 WOODSIDE CIR
Practice Address - Street 2:
Practice Address - City:DRESHER
Practice Address - State:PA
Practice Address - Zip Code:19025-1817
Practice Address - Country:US
Practice Address - Phone:630-926-5092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0421911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice