Healthcare Provider Details

I. General information

NPI: 1467452847
Provider Name (Legal Business Name): RICHARD GABRIEL PANKUCH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4466 DARROW RD SUITE 16
STOW OH
44224-1866
US

IV. Provider business mailing address

4466 DARROW RD SUITE 16
STOW OH
44224-1866
US

V. Phone/Fax

Practice location:
  • Phone: 330-688-3115
  • Fax: 330-688-3304
Mailing address:
  • Phone: 330-688-3115
  • Fax: 330-688-3304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number137393476
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: