Provider Demographics
NPI:1831304930
Name:PONICHTERA, ANDREW JOSEPH (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JOSEPH
Last Name:PONICHTERA
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 1:373 HOPMEADOW ST
Mailing Address - Street 2:P.O. BOX 316
Mailing Address - City:WEATOGUE
Mailing Address - State:CT
Mailing Address - Zip Code:06089-0316
Mailing Address - Country:US
Mailing Address - Phone:860-651-3319
Mailing Address - Fax:860-651-3314
Practice Address - Street 1:373 HOPMEADOW ST
Practice Address - Street 2:
Practice Address - City:WEATOGUE
Practice Address - State:CT
Practice Address - Zip Code:06089-9717
Practice Address - Country:US
Practice Address - Phone:860-651-3319
Practice Address - Fax:860-651-3314
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0068071223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU93335Medicare UPIN