Provider Demographics
NPI:1649252404
Name:PANG, HUP MAN (DDS)
Entity type:Individual
Prefix:MR
First Name:HUP
Middle Name:MAN
Last Name:PANG
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:PO BOX 166152
Mailing Address - Street 2:254 W 31ST ST
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-6152
Mailing Address - Country:US
Mailing Address - Phone:312-225-7970
Mailing Address - Fax:312-225-7522
Practice Address - Street 1:254 W 31ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-4494
Practice Address - Country:US
Practice Address - Phone:312-225-7970
Practice Address - Fax:312-225-7522
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1003227Medicaid