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General NPI Number Information
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NPI Number | 1063703643
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Entity Type | Organization
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Legal Business Name | LAGUNA CREEK FAMILY DENTISTRY
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Dates
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Enumeration Date | 04/29/2011
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Last Update Date | 04/29/2011
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Provider Practice Location Address
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Address Line | 5030 LAGUNA BLVD STE 108
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City | ELK GROVE
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State | CA
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Zip | 95758-4149
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Country | US
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Telephone | 916-684-4888
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Fax | 916-684-6999
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Provider Business Mailing Address
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Address Line | 5030 LAGUNA BLVD STE 108
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City | ELK GROVE
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State | CA
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Zip | 95758-4149
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Country | US
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Telephone | 916-684-4888
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Fax | 916-684-6999
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Authorized Official
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Title or Position | OWNER
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Name | DR. CURTIS P PON
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Credential | DDS
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Telephone | 916-684-4888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 39558
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License Number State | CA
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