Healthcare Provider Details

I. General information

NPI: 1093642100
Provider Name (Legal Business Name): BONANNO DENTAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11717 BERNARDO PLAZA CT STE 100
SAN DIEGO CA
92128-2419
US

IV. Provider business mailing address

11717 BERNARDO PLAZA CT STE 100
SAN DIEGO CA
92128-2419
US

V. Phone/Fax

Practice location:
  • Phone: 858-673-1633
  • Fax:
Mailing address:
  • Phone: 858-673-1633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID BONANNO
Title or Position: PRESIDENT / OWNER
Credential: DMD
Phone: 858-673-1633