Healthcare Provider Details

I. General information

NPI: 1164842191
Provider Name (Legal Business Name): PONCA FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 04/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 EAST STREET
PONCA NE
68770-0658
US

IV. Provider business mailing address

213 EAST STREET PO BOX 658
PONCA NE
68770-0658
US

V. Phone/Fax

Practice location:
  • Phone: 402-755-2291
  • Fax: 402-755-2292
Mailing address:
  • Phone: 402-755-2291
  • Fax: 402-755-2292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7008
License Number StateNE

VIII. Authorized Official

Name: NATALIE A FENDRICK
Title or Position: OWNER
Credential: DDS
Phone: 402-755-2291