Provider Demographics
NPI:1225260623
Name:TATH, PON T (DMD)
Entity Type:Individual
Prefix:
First Name:PON
Middle Name:T
Last Name:TATH
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:PO BOX 7783
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0783
Mailing Address - Country:US
Mailing Address - Phone:209-597-3145
Mailing Address - Fax:707-895-2035
Practice Address - Street 1:13500 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95415-9133
Practice Address - Country:US
Practice Address - Phone:707-895-3477
Practice Address - Fax:707-895-2035
Is Sole Proprietor?:No
Enumeration Date:2009-08-18
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA587061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice