Provider Demographics
NPI:1912188574
Name:PONDSIDE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:PONDSIDE ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:TIEU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:617-522-1970
Mailing Address - Street 1:P.O.BOX 301697
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130
Mailing Address - Country:US
Mailing Address - Phone:617-522-1970
Mailing Address - Fax:
Practice Address - Street 1:793 CENTRE ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2736
Practice Address - Country:US
Practice Address - Phone:617-522-1970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-23
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20059261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental