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General NPI Number Information
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NPI Number | 1235353392
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Entity Type | Organization
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Legal Business Name | BONNEY LAKE ORAL SURGERY
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Dates
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Enumeration Date | 04/12/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 8412 MYERS RD SUITE 101
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City | BONNEY LAKE
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State | WA
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Zip | 98391-5112
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Country | US
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Telephone | 253-863-2200
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Fax | 253-447-4968
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Provider Business Mailing Address
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Address Line | 8412 MYERS RD SUITE 101
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City | BONNEY LAKE
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State | WA
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Zip | 98391-5112
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Country | US
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Telephone | 253-863-2200
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Fax | 253-447-4968
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | ROSA MARIA CORTESI
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Credential |
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Telephone | 253-863-2200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DE00008264
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License Number State | WA
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