Healthcare Provider Details

I. General information

NPI: 1336142868
Provider Name (Legal Business Name): MARINA CELESTE BONAVENTURA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 ROSS ST
ASHEBORO NC
27203-5419
US

IV. Provider business mailing address

1002 ANNS CT
ASHEBORO NC
27205-7732
US

V. Phone/Fax

Practice location:
  • Phone: 336-318-1014
  • Fax:
Mailing address:
  • Phone: 336-318-1014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6005
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: