MEDICARE: DR. RODERICK FAJARDO PANGILINAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	54295	CA

General Provider Information

NPI Number	:	1386711901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RODERICK FAJARDO PANGILINAN

Provider Business Mailing Address
First Line	:	PO BOX 711314
Second Line	:
City	:	SANTEE
State	:	CA
Zip	:	92072-1314
Country	:	US
Telephone Number	:	619-677-0598
Fax Number	:

Provider Business Practice Location Address
First Line	:	4123 UNIVERSITY AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-1418
Country	:	US
Telephone Number	:	619-521-0033
Fax Number	:	619-521-0961

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	12/13/2011

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