Provider Demographics
NPI:1508886334
Name:PAN, RONG (DDS)
Entity Type:Individual
Prefix:
First Name:RONG
Middle Name:
Last Name:PAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:PAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 9279
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95157-0279
Mailing Address - Country:US
Mailing Address - Phone:408-255-0033
Mailing Address - Fax:408-255-0027
Practice Address - Street 1:5150 GRAVES AVE
Practice Address - Street 2:SUITE 11A
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129-5013
Practice Address - Country:US
Practice Address - Phone:408-255-0033
Practice Address - Fax:480-255-0027
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA451671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice