Provider Demographics
NPI:1740349448
Name:PANOSSIAN, ANTOINE (DMD)
Entity type:Individual
Prefix:DR
First Name:ANTOINE
Middle Name:
Last Name:PANOSSIAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 ROCKBOURNE RD
Mailing Address - Street 2:STE 400
Mailing Address - City:CLIFTON HEIGHTS
Mailing Address - State:PA
Mailing Address - Zip Code:19018-1739
Mailing Address - Country:US
Mailing Address - Phone:484-461-0128
Mailing Address - Fax:484-461-0130
Practice Address - Street 1:1247 S CEDAR CREST BLVD
Practice Address - Street 2:SUITE# 300
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6298
Practice Address - Country:US
Practice Address - Phone:484-550-6618
Practice Address - Fax:610-432-0233
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0362771223S0112X
NC201201857204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101236155Medicaid
PA101236155Medicaid