Healthcare Provider Details

I. General information

NPI: 1932734258
Provider Name (Legal Business Name): BONNIE MAREK DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2020
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 QUEEN VICTORIA AVENUE
MISSISSAUGA ONTARIO
L5H3H3
CA

IV. Provider business mailing address

1350 QUEEN VICTORIA AVENUE
MISSISSAUGA ONTARIO
L5H3H3
CA

V. Phone/Fax

Practice location:
  • Phone: 416-992-0721
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDN20464
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: