Provider Demographics
NPI:1235690884
Name:PONTILLO, DENISE
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:PONTILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8405 SHORE BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-7136
Mailing Address - Country:US
Mailing Address - Phone:702-294-0009
Mailing Address - Fax:
Practice Address - Street 1:8405 SHORE BREEZE DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-7136
Practice Address - Country:US
Practice Address - Phone:702-294-0009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty