Provider Demographics
NPI:1073982252
Name:PONSFORD, MITCHELL W (DMD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:W
Last Name:PONSFORD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 N MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-2036
Mailing Address - Country:US
Mailing Address - Phone:830-816-5102
Mailing Address - Fax:
Practice Address - Street 1:248 N MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006
Practice Address - Country:US
Practice Address - Phone:830-816-5102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-17
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX314341223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics