Healthcare Provider Details

I. General information

NPI: 1508902255
Provider Name (Legal Business Name): MICHAEL ROBERT PANZER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6529 INGLEWOOD AVE B-4
STOCKTON CA
95207-3864
US

IV. Provider business mailing address

6529 INGLEWOOD AVE B-4
STOCKTON CA
95207-3864
US

V. Phone/Fax

Practice location:
  • Phone: 209-478-2503
  • Fax: 209-478-7768
Mailing address:
  • Phone: 209-478-2503
  • Fax: 209-478-7768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number20246D
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: