Provider Demographics
NPI:1326510496
Name:LI, PENG-HAN
Entity Type:Individual
Prefix:
First Name:PENG-HAN
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2514 W FREDDY GONZALEZ DR STE 1
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-7339
Mailing Address - Country:US
Mailing Address - Phone:909-907-9788
Mailing Address - Fax:
Practice Address - Street 1:2514 W FREDDY GONZALEZ DR STE 1
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-7339
Practice Address - Country:US
Practice Address - Phone:909-907-9788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-29
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34769122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist