Healthcare Provider Details

I. General information

NPI: 1154893204
Provider Name (Legal Business Name): TAREN PANNU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2018
Last Update Date: 12/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 TEWKSBURY AVE STE A
POINT RICHMOND CA
94801-3829
US

IV. Provider business mailing address

16 WOODSTOCK CT
SAN RAFAEL CA
94903-4619
US

V. Phone/Fax

Practice location:
  • Phone: 415-755-5549
  • Fax:
Mailing address:
  • Phone: 415-755-5549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberRDHAP714
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: