Provider Demographics
NPI:1083766653
Name:PENG, WAN (DDS)
Entity Type:Individual
Prefix:MRS
First Name:WAN
Middle Name:
Last Name:PENG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-5008
Mailing Address - Country:US
Mailing Address - Phone:619-442-3131
Mailing Address - Fax:619-442-8445
Practice Address - Street 1:1106 N 2ND ST
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5008
Practice Address - Country:US
Practice Address - Phone:619-442-3131
Practice Address - Fax:619-442-8445
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA449851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice