Healthcare Provider Details

I. General information

NPI: 1598608994
Provider Name (Legal Business Name): ANDREA BONAVENTE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 BOSTON RD
JOINT BASE ANDREWS MD
20762
US

IV. Provider business mailing address

312 BEACHSIDE DR
STEVENSVILLE MD
21666-3914
US

V. Phone/Fax

Practice location:
  • Phone: 443-624-0602
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number18820
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: