Healthcare Provider Details

I. General information

NPI: 1679347033
Provider Name (Legal Business Name): DARTMOUTH MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2023
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2959 SHARPSBURG MCCULLUM RD # 103
NEWNAN GA
30265-2297
US

IV. Provider business mailing address

2959 SHARPSBURG MCCULLUM RD # 103
NEWNAN GA
30265-2297
US

V. Phone/Fax

Practice location:
  • Phone: 617-610-9339
  • Fax:
Mailing address:
  • Phone: 770-202-1642
  • Fax: 770-202-1643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: JIAN LIANG PANG
Title or Position: CEO
Credential: MD
Phone: 617-610-9339