Provider Demographics
NPI:1679747190
Name:PONQUINETTE, JUSTIN CHARLES (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:CHARLES
Last Name:PONQUINETTE
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 1:126 DEEPWATER CIR
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-4148
Mailing Address - Country:US
Mailing Address - Phone:718-704-3037
Mailing Address - Fax:
Practice Address - Street 1:970 CLIFTON AVE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-2731
Practice Address - Country:US
Practice Address - Phone:973-473-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI023699001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery