Provider Demographics
NPI:1912356486
Name:PONNUSAMY, PUNITA (DMD)
Entity Type:Individual
Prefix:DR
First Name:PUNITA
Middle Name:
Last Name:PONNUSAMY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 GINGER WOODS DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60502-7412
Mailing Address - Country:US
Mailing Address - Phone:630-946-9889
Mailing Address - Fax:
Practice Address - Street 1:1511 RIMSTONE DR
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-7692
Practice Address - Country:US
Practice Address - Phone:630-946-9889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-06
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX380301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice