Provider Demographics
NPI:1891803714
Name:PENG, CHICH-KUANG ERIC (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHICH-KUANG
Middle Name:ERIC
Last Name:PENG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:ERIC
Other - Middle Name:CK
Other - Last Name:PENG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:7615 GARVEY AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-3001
Mailing Address - Country:US
Mailing Address - Phone:626-307-4078
Mailing Address - Fax:626-307-9432
Practice Address - Street 1:7615 GARVEY AVE
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-3001
Practice Address - Country:US
Practice Address - Phone:626-307-4078
Practice Address - Fax:626-307-9432
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA350171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93553-01Medicaid