Provider Demographics
NPI:1851693295
Name:PONCE DE LEON DENTAL
Entity Type:Organization
Organization Name:PONCE DE LEON DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:PONCE DE LEON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:916-564-2020
Mailing Address - Street 1:1589 W. EL CAMINO AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833
Mailing Address - Country:US
Mailing Address - Phone:916-564-2020
Mailing Address - Fax:916-564-3900
Practice Address - Street 1:1589 W. EL CAMINO AVE.
Practice Address - Street 2:STE. 108
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95833
Practice Address - Country:US
Practice Address - Phone:916-564-2020
Practice Address - Fax:916-564-3900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40875122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty