Provider Demographics
NPI:1063703643
Name:LAGUNA CREEK FAMILY DENTISTRY
Entity type:Organization
Organization Name:LAGUNA CREEK FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:P
Authorized Official - Last Name:PON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-684-4888
Mailing Address - Street 1:5030 LAGUNA BLVD STE 108
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-4149
Mailing Address - Country:US
Mailing Address - Phone:916-684-4888
Mailing Address - Fax:916-684-6999
Practice Address - Street 1:5030 LAGUNA BLVD STE 108
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-4149
Practice Address - Country:US
Practice Address - Phone:916-684-4888
Practice Address - Fax:916-684-6999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39558122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty