Provider Demographics
NPI:1033807615
Name:PANNU, BALJOT (DDS)
Entity Type:Individual
Prefix:
First Name:BALJOT
Middle Name:
Last Name:PANNU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19-A HIGH STREET
Mailing Address - Street 2:#118
Mailing Address - City:FORT ERIE
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L2A 5W7
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:80 ERDMAN WAY STE 201
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-1840
Practice Address - Country:US
Practice Address - Phone:978-840-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-01
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN1859748122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program