Provider Demographics
NPI:1902819980
Name:PAN, CHARLES HENRY (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:HENRY
Last Name:PAN
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 1:27020 PACIFIC HWY S
Mailing Address - Street 2:#C
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-6902
Mailing Address - Country:US
Mailing Address - Phone:253-529-9434
Mailing Address - Fax:253-529-1286
Practice Address - Street 1:27020 PACIFIC HWY S
Practice Address - Street 2:#C
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-6902
Practice Address - Country:US
Practice Address - Phone:253-529-9434
Practice Address - Fax:253-529-1286
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00007305122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5022967Medicaid