Provider Demographics
NPI:1154544666
Name:PONTIOUS, PHILLIP EARL (DMD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:EARL
Last Name:PONTIOUS
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 1:1204 MAIN ST
Mailing Address - Street 2:CANON CITY
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-3506
Mailing Address - Country:US
Mailing Address - Phone:719-275-2887
Mailing Address - Fax:719-275-2761
Practice Address - Street 1:1204 MAIN ST
Practice Address - Street 2:CANON CITY
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-3506
Practice Address - Country:US
Practice Address - Phone:719-275-2887
Practice Address - Fax:719-275-2761
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO92271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice