Provider Demographics
NPI:1326141102
Name:PANK, DENNIS J (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:J
Last Name:PANK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1455
Mailing Address - Country:US
Mailing Address - Phone:810-424-2011
Mailing Address - Fax:
Practice Address - Street 1:1096 S BELSAY RD
Practice Address - Street 2:STE C
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1948
Practice Address - Country:US
Practice Address - Phone:810-743-3351
Practice Address - Fax:810-244-1239
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047915207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1326141102Medicaid
MIPENDINGMedicare PIN
MI3235379Medicaid