MEDICARE: LAGUNA CREEK FAMILY DENTISTRY

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	39558	CA

General Provider Information

NPI Number	:	1063703643
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAGUNA CREEK FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	5030 LAGUNA BLVD STE 108
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95758-4149
Country	:	US
Telephone Number	:	916-684-4888
Fax Number	:	916-684-6999

Provider Business Practice Location Address
First Line	:	5030 LAGUNA BLVD STE 108
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95758-4149
Country	:	US
Telephone Number	:	916-684-4888
Fax Number	:	916-684-6999

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CURTIS P PON
Credential	:	DDS
Telephone Number	:	916-684-4888

Provider Enumeration Date	:	04/29/2011
Last Update Date	:	04/29/2011

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