Provider Demographics
NPI:1508423591
Name:PAN, JASON LIDDELL (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:LIDDELL
Last Name:PAN
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 1:94 LARCHMONT RD
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-2503
Mailing Address - Country:US
Mailing Address - Phone:617-272-5677
Mailing Address - Fax:
Practice Address - Street 1:985 MAIN ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-1913
Practice Address - Country:US
Practice Address - Phone:781-665-5190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2020-08-26
Deactivation Date:2019-05-24
Deactivation Code:
Reactivation Date:2019-06-06
Provider Licenses
StateLicense IDTaxonomies
MADN18586381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice