Healthcare Provider Details

I. General information

NPI: 1730851429
Provider Name (Legal Business Name): PONDEROSA FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2021
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 W WINNIE LN STE 2
CARSON CITY NV
89703-2145
US

IV. Provider business mailing address

3605 GRANT DR
RENO NV
89509-5301
US

V. Phone/Fax

Practice location:
  • Phone: 775-885-2323
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: ALETA BEUTER
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 775-409-4614