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General NPI Number Information
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NPI Number | 1477783199
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Entity Type | Organization
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Legal Business Name | BONNEY LAKE DENTAL CENTER
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Dates
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Enumeration Date | 07/15/2009
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Last Update Date | 07/15/2009
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Provider Practice Location Address
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Address Line | 9925 214TH AVE E STE A
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City | BONNEY LAKE
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State | WA
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Zip | 98391-3910
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Country | US
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Telephone | 253-863-4594
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Fax | 253-863-5061
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Provider Business Mailing Address
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Address Line | 9925 214TH AVE E STE A
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City | BONNEY LAKE
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State | WA
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Zip | 98391-3910
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Country | US
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Telephone | 253-863-4594
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Fax | 253-863-5061
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Authorized Official
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Title or Position | DENTIST
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Name | MRS. DELIA CONSTANTIN
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Credential | DDS
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Telephone | 253-863-4594
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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