MEDICARE: PHILLIP EARL PONTIOUS DMD

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	1223G0001X	General Practice Dentistry	9227	CO

General Provider Information

NPI Number	:	1154544666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILLIP EARL PONTIOUS DMD

Provider Business Mailing Address
First Line	:	1204 MAIN ST
Second Line	:	CANON CITY
City	:	CANON CITY
State	:	CO
Zip	:	81212-3506
Country	:	US
Telephone Number	:	719-275-2887
Fax Number	:	719-275-2761

Provider Business Practice Location Address
First Line	:	1204 MAIN ST
Second Line	:	CANON CITY
City	:	CANON CITY
State	:	CO
Zip	:	81212-3506
Country	:	US
Telephone Number	:	719-275-2887
Fax Number	:	719-275-2761

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

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	07/08/2007

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