Provider Demographics
NPI:1457706202
Name:PONNUSAMY, SHOUVIK (DMD)
Entity Type:Individual
Prefix:
First Name:SHOUVIK
Middle Name:
Last Name:PONNUSAMY
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 1:1511 RIMSTONE DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-7692
Mailing Address - Country:US
Mailing Address - Phone:630-267-1199
Mailing Address - Fax:
Practice Address - Street 1:4010 SANDY BROOK DR STE 204
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-1518
Practice Address - Country:US
Practice Address - Phone:512-456-3161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-29
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX380501223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program