Provider Demographics
NPI:1962524967
Name:MATERUM, PONS TAMONDONG JR (DDS)
Entity type:Individual
Prefix:
First Name:PONS
Middle Name:TAMONDONG
Last Name:MATERUM
Suffix:JR
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 1:343 GELLERT BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015
Mailing Address - Country:US
Mailing Address - Phone:650-991-0611
Mailing Address - Fax:650-992-0218
Practice Address - Street 1:343 GELLERT BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015
Practice Address - Country:US
Practice Address - Phone:650-991-0611
Practice Address - Fax:650-992-0218
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA036979122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist