Provider Demographics
NPI:1629113543
Name:PANCZYSZYN, JOHN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:PANCZYSZYN
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 1:938 BRIDGEWATER DR
Mailing Address - Street 2:UNIT 3B
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-4139
Mailing Address - Country:US
Mailing Address - Phone:386-756-3728
Mailing Address - Fax:386-756-3654
Practice Address - Street 1:938 BRIDGEWATER DR
Practice Address - Street 2:UNIT 3B
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-4139
Practice Address - Country:US
Practice Address - Phone:386-756-3728
Practice Address - Fax:386-756-3654
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0009950122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
43352OtherUNITED CONCORDIA