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General NPI Number Information
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NPI Number | 1063675973
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Entity Type | Organization
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Legal Business Name | PONCE TENDER DENTAL PD
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Dates
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Enumeration Date | 07/10/2008
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Last Update Date | 07/10/2008
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Provider Practice Location Address
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Address Line | 5230 BOULDER HIGHWAY SUITE 130
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City | LAS VEGAS
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State | NV
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Zip | 89122
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Country | US
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Telephone | 702-436-6725
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Fax | 702-995-0116
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Provider Business Mailing Address
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Address Line | 5230 BOULDER HIGHWAY SUITE 130
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City | LAS VEGAS
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State | NV
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Zip | 89122
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Country | US
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Telephone | 702-436-6725
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Fax | 702-995-0116
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Authorized Official
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Title or Position | OWNER
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Name | MONICA RENEE PONCE
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Credential | DDS
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Telephone | 702-436-6725
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 3063
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License Number State | NV
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