Basic Information
Provider Information
NPI: 1649656299
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HAN
FirstName: PAMELA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 10940 TRINITY PKWY
Address2: C123
City: STOCKTON
State: CA
PostalCode: 952197234
CountryCode: US
TelephoneNumber: 9497353900
FaxNumber:  
Practice Location
Address1: 10928 TRINITY PKWY
Address2:  
City: STOCKTON
State: CA
PostalCode: 952197230
CountryCode: US
TelephoneNumber: 2094748000
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/06/2015
LastUpdateDate: 08/06/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X64739CAY Dental ProvidersDentistGeneral Practice

No ID Information.


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