Healthcare Provider Details

I. General information

NPI: 1568845949
Provider Name (Legal Business Name): JAY PONTO MD, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2015
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 7TH AVE S
BIRMINGHAM AL
35233-2005
US

IV. Provider business mailing address

1919 7TH AVE S
BIRMINGHAM AL
35233-2005
US

V. Phone/Fax

Practice location:
  • Phone: 205-934-3411
  • Fax:
Mailing address:
  • Phone: 205-934-4011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number63540
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number46593
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number46593
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: