Healthcare Provider Details

I. General information

NPI: 1295061547
Provider Name (Legal Business Name): MARVIN HAMILTON BOHNENKAMP DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2009
Last Update Date: 10/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 EAGLE CT
FARMINGTON MO
63640-7660
US

IV. Provider business mailing address

4 EAGLE CT
FARMINGTON MO
63640-7660
US

V. Phone/Fax

Practice location:
  • Phone: 573-701-4433
  • Fax:
Mailing address:
  • Phone: 573-701-4433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number012274
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: