Healthcare Provider Details

I. General information

NPI: 1740349448
Provider Name (Legal Business Name): ANTOINE PANOSSIAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 01/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1247 S CEDAR CREST BLVD SUITE# 300
ALLENTOWN PA
18103-6298
US

IV. Provider business mailing address

4 ROCKBOURNE RD STE 400
CLIFTON HEIGHTS PA
19018-1739
US

V. Phone/Fax

Practice location:
  • Phone: 484-550-6618
  • Fax: 610-432-0233
Mailing address:
  • Phone: 484-461-0128
  • Fax: 484-461-0130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS036277
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number201201857
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: