Provider Demographics
NPI:1154893204
Name:PANNU, TAREN
Entity type:Individual
Prefix:
First Name:TAREN
Middle Name:
Last Name:PANNU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 WOODSTOCK CT
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-4619
Mailing Address - Country:US
Mailing Address - Phone:415-755-5549
Mailing Address - Fax:
Practice Address - Street 1:229 TEWKSBURY AVE STE A
Practice Address - Street 2:
Practice Address - City:POINT RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94801-3829
Practice Address - Country:US
Practice Address - Phone:415-755-5549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDHAP714124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARDHAP714OtherDHCC