Provider Demographics
NPI:1750819264
Name:PONKOWSKI, TIMOTHY J JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:PONKOWSKI
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62807 TOURNAMENT DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48094-1564
Mailing Address - Country:US
Mailing Address - Phone:313-820-7002
Mailing Address - Fax:
Practice Address - Street 1:11453 15 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-3809
Practice Address - Country:US
Practice Address - Phone:586-939-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-28
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010222631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice