=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457857146
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA LAUREN BONSER DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2018
-----------------------------------------------------
Last Update Date | 11/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3595 S FLORIDA AVE
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33803-4860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-462-4463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3408 W GABLES CT
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33609-2965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-478-7996
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 23560
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------