Provider Demographics
NPI:1760081954
Name:PANKAJ, AMLAN
Entity Type:Individual
Prefix:DR
First Name:AMLAN
Middle Name:
Last Name:PANKAJ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2607 WOLFLIN AVE # 901
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-1825
Mailing Address - Country:US
Mailing Address - Phone:631-561-5464
Mailing Address - Fax:
Practice Address - Street 1:802 E AMARILLO BLVD # 300
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79107-5401
Practice Address - Country:US
Practice Address - Phone:806-553-7877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36804122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist