Healthcare Provider Details

I. General information

NPI: 1376400663
Provider Name (Legal Business Name): DAKOTA NATALE BONANNO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2026
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11655 QUEENS BLVD STE 216
FOREST HILLS NY
11375-6527
US

IV. Provider business mailing address

11655 QUEENS BLVD STE 216
FOREST HILLS NY
11375-6527
US

V. Phone/Fax

Practice location:
  • Phone: 212-470-1382
  • Fax:
Mailing address:
  • Phone: 212-470-1382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: