Healthcare Provider Details

I. General information

NPI: 1205045382
Provider Name (Legal Business Name): JOSEPH DAVIN BONAVILLA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 COOK RD
ORANGEBURG SC
29118-2126
US

IV. Provider business mailing address

888 COOK RD
ORANGEBURG SC
29118-2126
US

V. Phone/Fax

Practice location:
  • Phone: 803-516-0777
  • Fax: 803-516-0577
Mailing address:
  • Phone: 803-516-0777
  • Fax: 803-516-0577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number4305
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN013507
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number50-051910
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number3516
License Number StateWV
# 5
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401411675
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: