Provider Demographics
NPI:1619047321
Name:PANNECK, WILLIAM LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:LEE
Last Name:PANNECK
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 1:1203 WOOD CV
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5701
Mailing Address - Country:US
Mailing Address - Phone:870-935-7958
Mailing Address - Fax:870-932-5717
Practice Address - Street 1:1803 WOODSPRINGS RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-0903
Practice Address - Country:US
Practice Address - Phone:870-932-8488
Practice Address - Fax:870-932-5717
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR24231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR562235OtherBCBS-BLUE ADVANTAGE
AR58820OtherBCBS - FEDERAL