Provider Demographics
NPI:1871629097
Name:FENG, BO
Entity Type:Individual
Prefix:
First Name:BO
Middle Name:
Last Name:FENG
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 1:1503 BANIDA AVE
Mailing Address - Street 2:
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748-2344
Mailing Address - Country:US
Mailing Address - Phone:626-378-4248
Mailing Address - Fax:
Practice Address - Street 1:14248 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-7008
Practice Address - Country:US
Practice Address - Phone:310-978-2974
Practice Address - Fax:310-978-0451
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55448122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist