Basic Information
Provider Information | |||||||||
NPI: | 1982180360 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PANGBORN FAMILY DENTISTRY LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 520 SUMMIT AVE | ||||||||
Address2: |   | ||||||||
City: | HACKENSACK | ||||||||
State: | NJ | ||||||||
PostalCode: | 076011550 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2014889030 | ||||||||
FaxNumber: | 2014889130 | ||||||||
Practice Location | |||||||||
Address1: | 35 PANGBORN PL | ||||||||
Address2: |   | ||||||||
City: | HACKENSACK | ||||||||
State: | NJ | ||||||||
PostalCode: | 076014506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2018010101 | ||||||||
FaxNumber: | 2014889130 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2018 | ||||||||
LastUpdateDate: | 07/18/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHISOLM | ||||||||
AuthorizedOfficialFirstName: | TWANIQUA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2014889030 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223E0200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Endodontics | 1223P0221X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry | 1223S0112X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223G0001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.