Provider Demographics
NPI:1912517228
Name:PENG, COSMO YUCHEN (DDS)
Entity Type:Individual
Prefix:
First Name:COSMO
Middle Name:YUCHEN
Last Name:PENG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1062 NW DEERFERN LOOP
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-8689
Mailing Address - Country:US
Mailing Address - Phone:360-921-3656
Mailing Address - Fax:
Practice Address - Street 1:19111 SE 34TH ST STE 104
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-1449
Practice Address - Country:US
Practice Address - Phone:360-823-0427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD112781223G0001X
WADE612176271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice