Provider Demographics
NPI:1144613670
Name:KO, PANG (DMD)
Entity Type:Individual
Prefix:
First Name:PANG
Middle Name:
Last Name:KO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 NIGHTINGALE AVE BUILDING 5513
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CA
Mailing Address - Zip Code:93524-0001
Mailing Address - Country:US
Mailing Address - Phone:661-277-2872
Mailing Address - Fax:
Practice Address - Street 1:30 NIGHTINGALE AVE BUILDING 5513
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CA
Practice Address - Zip Code:93524-0001
Practice Address - Country:US
Practice Address - Phone:661-277-2872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-09
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA64986122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program