Provider Demographics
NPI:1467452847
Name:PANKUCH, RICHARD GABRIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:GABRIEL
Last Name:PANKUCH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4466 DARROW RD
Mailing Address - Street 2:SUITE 16
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-1866
Mailing Address - Country:US
Mailing Address - Phone:330-688-3115
Mailing Address - Fax:330-688-3304
Practice Address - Street 1:4466 DARROW RD
Practice Address - Street 2:SUITE 16
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-1866
Practice Address - Country:US
Practice Address - Phone:330-688-3115
Practice Address - Fax:330-688-3304
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1373934761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice