Provider Demographics
NPI:1750908075
Name:PENG, LIN (DMD)
Entity type:Individual
Prefix:
First Name:LIN
Middle Name:
Last Name:PENG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:787 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-7486
Mailing Address - Country:US
Mailing Address - Phone:646-407-0233
Mailing Address - Fax:
Practice Address - Street 1:1484 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-6555
Practice Address - Country:US
Practice Address - Phone:606-666-9950
Practice Address - Fax:606-666-9136
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10489122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist