Healthcare Provider Details

I. General information

NPI: 1205406329
Provider Name (Legal Business Name): OLIVIA MINJIA PAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 07/12/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6428 GEORGIA AVE NW
WASHINGTON DC
20012-2910
US

IV. Provider business mailing address

6428 GEORGIA AVE NW
WASHINGTON DC
20012-2910
US

V. Phone/Fax

Practice location:
  • Phone: 202-723-0303
  • Fax:
Mailing address:
  • Phone: 202-723-0303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN2000059
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: