Healthcare Provider Details

I. General information

NPI: 1760500169
Provider Name (Legal Business Name): ARISTIDIS PONTIKAS DMD MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 10/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 EAST BETHANY HOME ROAD SUITE B-120
PHOENIX AZ
85012
US

IV. Provider business mailing address

301 EAST BETHANY HOME ROAD SUITE B-120
PHOENIX AZ
85012
US

V. Phone/Fax

Practice location:
  • Phone: 623-934-1676
  • Fax: 623-934-6630
Mailing address:
  • Phone: 623-934-1676
  • Fax: 623-934-6630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number50973
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number20727
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: