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General NPI Number Information
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NPI Number | 1376763201
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Entity Type | Individual
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Provider Name | MICHELLE BONGIOVI DMD
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Gender | Female
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Dates
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Enumeration Date | 04/25/2007
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Last Update Date | 10/03/2024
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Provider Practice Location Address
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Address Line | HURLBURT FIELD USAF 1SOMDG/SGDD, BLDG 91202
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City | DPO
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State | AA
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Zip | 32544
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Country | US
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Telephone | 850-884-7881
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Fax |
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Provider Business Mailing Address
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Address Line | HURLBURT FIELD BLDG 91202,
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City | DPO
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State | AA
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Zip | 32544
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Country | US
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Telephone | 850-884-7881
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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 | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 3070
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License Number State | NV
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