Provider Demographics
NPI:1093925323
Name:PANNKUK, TERRELL FRED (DDS, MSCD)
Entity Type:Individual
Prefix:DR
First Name:TERRELL
Middle Name:FRED
Last Name:PANNKUK
Suffix:
Gender:M
Credentials:DDS, MSCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9 EAST PEDREGOSA STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101
Mailing Address - Country:US
Mailing Address - Phone:805-682-0055
Mailing Address - Fax:805-682-6451
Practice Address - Street 1:9 EAST PEDREGOSA STREET
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93101
Practice Address - Country:US
Practice Address - Phone:805-682-0055
Practice Address - Fax:805-682-6451
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA324451223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU4632Medicaid