Provider Demographics
NPI:1548540602
Name:PONDER, STACY (DMD)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:
Last Name:PONDER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1157 LANDON LN
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-4933
Mailing Address - Country:US
Mailing Address - Phone:601-408-2414
Mailing Address - Fax:
Practice Address - Street 1:508 W MCDERMOTT DR
Practice Address - Street 2:SUITE 130
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-2777
Practice Address - Country:US
Practice Address - Phone:972-908-3399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX274001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics