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General NPI Number Information
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NPI Number | 1033888201
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Entity Type | Individual
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Provider Name | EMILIE BONOVITCH ELLIS RDH
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Gender | Female
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Dates
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Enumeration Date | 09/10/2021
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Last Update Date | 09/10/2021
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Provider Practice Location Address
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Address Line | 27 BRIGGS DR STE A
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City | MANAKIN SABOT
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State | VA
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Zip | 23103-2250
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Country | US
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Telephone | 804-784-2386
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Fax |
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Provider Business Mailing Address
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Address Line | 8801 NESBIT FERRY LN
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City | CHESTERFIELD
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State | VA
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Zip | 23832-2133
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Country | US
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Telephone | 804-349-8146
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 0402206328
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License Number State | VA
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