Basic Information
Provider Information
NPI: 1811941966
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PONG
FirstName: CINDY
MiddleName: R
NamePrefix:  
NameSuffix:  
Credential: D.D.S.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3333 BURNET AVE
Address2: ML 5021
City: CINCINNATI
State: OH
PostalCode: 452293039
CountryCode: US
TelephoneNumber: 5136364225
FaxNumber: 5136362511
Practice Location
Address1: 3333 BURNET AVE
Address2: ML 2006
City: CINCINNATI
State: OH
PostalCode: 452293039
CountryCode: US
TelephoneNumber: 5136364641
FaxNumber: 5136368283
Other Information
ProviderEnumerationDate: 05/22/2006
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: X
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223P0221X30.020266OHY Dental ProvidersDentistPediatric Dentistry

No ID Information.


Home