Healthcare Provider Details

I. General information

NPI: 1811549918
Provider Name (Legal Business Name): DAVID RICHARD BONANNO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
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: 858-673-0093
Mailing address:
  • Phone: 858-673-1633
  • Fax: 858-673-0093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00203979
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN.00203979
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: