Healthcare Provider Details

I. General information

NPI: 1255243721
Provider Name (Legal Business Name): KLEBER CORTES BONIFACIO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5979 VINELAND RD
ORLANDO FL
32819-7800
US

IV. Provider business mailing address

5979 VINELAND RD
ORLANDO FL
32819-7800
US

V. Phone/Fax

Practice location:
  • Phone: 407-842-9152
  • Fax:
Mailing address:
  • Phone: 407-842-9152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number016.0134471
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: