Healthcare Provider Details

I. General information

NPI: 1497827174
Provider Name (Legal Business Name): BONANN GIFFORD GILL RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

592 ROCKAWAY AVE
BROOKLYN NY
11212-5539
US

IV. Provider business mailing address

915 E 40TH ST
BROOKLYN NY
11210-3509
US

V. Phone/Fax

Practice location:
  • Phone: 718-345-5000
  • Fax: 718-346-6747
Mailing address:
  • Phone: 718-345-5000
  • Fax: 718-346-6747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number021860
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: