Provider Demographics
NPI:1205406329
Name:PAN, OLIVIA MINJIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:OLIVIA
Middle Name:MINJIA
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 1:6428 GEORGIA AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20012-2910
Mailing Address - Country:US
Mailing Address - Phone:202-723-0303
Mailing Address - Fax:
Practice Address - Street 1:6428 GEORGIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-2910
Practice Address - Country:US
Practice Address - Phone:202-723-0303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN2000059122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist