Provider Demographics
NPI:1164842191
Name:PONCA FAMILY DENTISTRY
Entity Type:Organization
Organization Name:PONCA FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:FENDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-755-2291
Mailing Address - Street 1:213 EAST STREET
Mailing Address - Street 2:PO BOX 658
Mailing Address - City:PONCA
Mailing Address - State:NE
Mailing Address - Zip Code:68770-0658
Mailing Address - Country:US
Mailing Address - Phone:402-755-2291
Mailing Address - Fax:402-755-2292
Practice Address - Street 1:213 EAST STREET
Practice Address - Street 2:
Practice Address - City:PONCA
Practice Address - State:NE
Practice Address - Zip Code:68770-0658
Practice Address - Country:US
Practice Address - Phone:402-755-2291
Practice Address - Fax:402-755-2292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7008122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025084300Medicaid