Provider Demographics
NPI:1902182041
Name:JIERU PAN DDS A PROFESSIONAL CORP.
Entity Type:Organization
Organization Name:JIERU PAN DDS A PROFESSIONAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JIERU
Authorized Official - Middle Name:
Authorized Official - Last Name:PAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-484-9154
Mailing Address - Street 1:1818 SIERRA LEONE AVE.
Mailing Address - Street 2:SUITE C
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748
Mailing Address - Country:US
Mailing Address - Phone:626-581-9152
Mailing Address - Fax:626-581-9155
Practice Address - Street 1:1818 SIERRA LEONE AVE.
Practice Address - Street 2:SUITE C
Practice Address - City:ROWLAND HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91748
Practice Address - Country:US
Practice Address - Phone:626-581-9152
Practice Address - Fax:626-581-9155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51123122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty