MEDICARE: DR. BONITA LYNN PRUITT DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	14977	TX

General Provider Information

NPI Number	:	1770562415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BONITA LYNN PRUITT DDS

Provider Business Mailing Address
First Line	:	US ARMY DENTAL ACTIVITY ATTN CREDENTIALS COORDINATOR
Second Line	:	10205 NORTH RIVA RIDGE LOOP
City	:	FORT DRUM
State	:	NY
Zip	:	13603-5005
Country	:	US
Telephone Number	:	315-772-4342
Fax Number	:	315-772-9692

Provider Business Practice Location Address
First Line	:	US ARMY DENTAL ACTIVITY ATTN CREDENTIALS COORDINATOR
Second Line	:	10205 NORTH RIVA RIDGE LOOP
City	:	FORT DRUM
State	:	NY
Zip	:	13603-5005
Country	:	US
Telephone Number	:	315-772-4342
Fax Number	:	315-772-9692

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2006
Last Update Date	:	07/08/2007

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