Provider Demographics
NPI:1508943572
Name:NELSON PAN DDS DEBRA HONG PAN DMD MS LLC
Entity Type:Organization
Organization Name:NELSON PAN DDS DEBRA HONG PAN DMD MS LLC
Other - Org Name:NELSON PAN DDS DEBRA HONG PAN DMD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:
Authorized Official - Last Name:PAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:781-665-5190
Mailing Address - Street 1:985 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-1913
Mailing Address - Country:US
Mailing Address - Phone:781-665-5190
Mailing Address - Fax:781-979-0682
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:781-979-0682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA161331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA86256OtherUNITED CONCORDIA
MAXO5663OtherBCBS