Healthcare Provider Details

I. General information

NPI: 1699425686
Provider Name (Legal Business Name): TODD BONESTEEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 01/14/2024
Certification Date: 01/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5835 E STILL CIR
MESA AZ
85206-3618
US

IV. Provider business mailing address

66 SUMNER ST
QUINCY MA
02169-7038
US

V. Phone/Fax

Practice location:
  • Phone: 480-219-6000
  • Fax:
Mailing address:
  • Phone: 518-763-8160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD011662
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: