Provider Demographics
NPI:1750875662
Name:PENG, CONG (DMD)
Entity type:Individual
Prefix:DR
First Name:CONG
Middle Name:
Last Name:PENG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3433 COVE VIEW BLVD APT 3533
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77554-8175
Mailing Address - Country:US
Mailing Address - Phone:781-627-6588
Mailing Address - Fax:
Practice Address - Street 1:6821 STEWART RD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77551-1841
Practice Address - Country:US
Practice Address - Phone:781-627-6588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-15
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX341441223G0001X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX34144OtherDENTAL LICENSE