Provider Demographics
NPI:1811686579
Name:LOR, KONG PENG
Entity type:Individual
Prefix:
First Name:KONG
Middle Name:PENG
Last Name:LOR
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 1:86 N MITCHELL AVE
Mailing Address - Street 2:
Mailing Address - City:BAKERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28705-6502
Mailing Address - Country:US
Mailing Address - Phone:828-688-2104
Mailing Address - Fax:
Practice Address - Street 1:89 N MITCHELL AVE
Practice Address - Street 2:
Practice Address - City:BAKERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28705-6502
Practice Address - Country:US
Practice Address - Phone:828-537-5991
Practice Address - Fax:732-393-8492
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC142761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program