MEDICARE: RICHARD W PANEK DDS

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	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	2901015266	MI

General Provider Information

NPI Number	:	1740371087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD W PANEK DDS

Provider Business Mailing Address
First Line	:	4349 SAWKAW DR NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-1768
Country	:	US
Telephone Number	:	616-361-7327
Fax Number	:

Provider Business Practice Location Address
First Line	:	4349 SAWKAW DR NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-1768
Country	:	US
Telephone Number	:	616-361-7327
Fax Number	:

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

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	02/04/2022

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