Provider Demographics
NPI:1841213808
Name:PONCE, ROLANDO (DDS)
Entity type:Individual
Prefix:DR
First Name:ROLANDO
Middle Name:
Last Name:PONCE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15711 MAPLEDALE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-3112
Mailing Address - Country:US
Mailing Address - Phone:813-264-0286
Mailing Address - Fax:813-960-4667
Practice Address - Street 1:12207 N FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4213
Practice Address - Country:US
Practice Address - Phone:813-930-9406
Practice Address - Fax:813-930-9416
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN-12772122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL073648100Medicaid