Healthcare Provider Details

I. General information

NPI: 1366567380
Provider Name (Legal Business Name): ANDREA MARIE BONNICK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 GEORGIA AVE NW SUITE 4C-46
WASHINGTON DC
20060-0001
US

IV. Provider business mailing address

15150 PAWLEYS PL
WALDORF MD
20601-5419
US

V. Phone/Fax

Practice location:
  • Phone: 202-865-1361
  • Fax: 202-865-3323
Mailing address:
  • Phone: 202-865-1361
  • Fax: 202-865-3323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN5626
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: