Provider Demographics
NPI:1730851429
Name:PONDEROSA FAMILY DENTAL
Entity type:Organization
Organization Name:PONDEROSA FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ALETA
Authorized Official - Middle Name:
Authorized Official - Last Name:BEUTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-409-4614
Mailing Address - Street 1:3605 GRANT DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-5301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:307 W WINNIE LN STE 2
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-2145
Practice Address - Country:US
Practice Address - Phone:775-885-2323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000OtherNO OTHER