Provider Demographics
NPI:1184823957
Name:PAN, JIERU (DDS)
Entity Type:Individual
Prefix:DR
First Name:JIERU
Middle Name:
Last Name:PAN
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 1:22514 MOUNTAIN LAUREL WAY
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-2522
Mailing Address - Country:US
Mailing Address - Phone:909-861-6310
Mailing Address - Fax:
Practice Address - Street 1:22514 MOUNTAIN LAUREL WAY
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-2522
Practice Address - Country:US
Practice Address - Phone:909-861-6310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA511231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice