Provider Demographics
NPI:1982180360
Name:PANGBORN FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:PANGBORN FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TWANIQUA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHISOLM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-488-9030
Mailing Address - Street 1:520 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1550
Mailing Address - Country:US
Mailing Address - Phone:201-488-9030
Mailing Address - Fax:201-488-9130
Practice Address - Street 1:35 PANGBORN PL
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-4506
Practice Address - Country:US
Practice Address - Phone:201-801-0101
Practice Address - Fax:201-488-9130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty