Provider Demographics
NPI:1124163704
Name:PONICHTERA, PAUL WALTER (DMD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:WALTER
Last Name:PONICHTERA
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:BOX 870061
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02187-0061
Mailing Address - Country:US
Mailing Address - Phone:617-696-4300
Mailing Address - Fax:
Practice Address - Street 1:25 HIGH ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-3426
Practice Address - Country:US
Practice Address - Phone:617-696-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA115951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice