Basic Information
Provider Information
NPI: 1609061274
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PANGBORN
FirstName: WILLARD
MiddleName: HENRY
NamePrefix: DR.
NameSuffix: JR.
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 71 63RD PL
Address2:  
City: LONG BEACH
State: CA
PostalCode: 908035675
CountryCode: US
TelephoneNumber: 5624346072
FaxNumber:  
Practice Location
Address1: 2737 W. CECIL
Address2:  
City: DELANO
State: CA
PostalCode: 93216
CountryCode: US
TelephoneNumber: 6617212345
FaxNumber: 6617216289
Other Information
ProviderEnumerationDate: 09/07/2007
LastUpdateDate: 09/07/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X16607CAY Dental ProvidersDentist 

No ID Information.


Home