Healthcare Provider Details

I. General information

NPI: 1497980353
Provider Name (Legal Business Name): BONNIE SUE THRASHER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2009
Last Update Date: 05/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 DAYSPRING PL
PAGOSA SPRINGS CO
81147-9140
US

IV. Provider business mailing address

PO BOX 5948
PAGOSA SPRINGS CO
81147-5948
US

V. Phone/Fax

Practice location:
  • Phone: 970-731-3393
  • Fax:
Mailing address:
  • Phone: 970-731-3393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number902868
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: