Provider Demographics
NPI:1043540164
Name:PENG, ROSA (DMD, MSD)
Entity Type:Individual
Prefix:DR
First Name:ROSA
Middle Name:
Last Name:PENG
Suffix:
Gender:F
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 N BROADWAY STE A
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706-3929
Mailing Address - Country:US
Mailing Address - Phone:714-667-0411
Mailing Address - Fax:
Practice Address - Street 1:10600 MAGNOLIA AVE STE A
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-1819
Practice Address - Country:US
Practice Address - Phone:951-359-8100
Practice Address - Fax:951-359-1184
Is Sole Proprietor?:No
Enumeration Date:2010-01-12
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA451331223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics