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General NPI Number Information
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NPI Number | 1780841213
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Entity Type | Organization
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Legal Business Name | ANDREW BONAVITA DMDPC
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Dates
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Enumeration Date | 05/21/2008
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Last Update Date | 05/21/2008
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Provider Practice Location Address
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Address Line | 123 DWIGHT RD
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City | LONGMEADOW
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State | MA
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Zip | 01106-1748
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Country | US
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Telephone | 413-567-7735
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Fax | 413-565-2579
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Provider Business Mailing Address
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Address Line | 123 DWIGHT RD
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City | LONGMEADOW
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State | MA
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Zip | 01106-1748
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Country | US
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Telephone | 413-567-7735
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Fax | 413-565-2579
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Authorized Official
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Title or Position | PRESIDENT
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Name | ANDREW O BONAVITA
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Credential | DMD
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Telephone | 413-567-7735
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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 | 17903
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License Number State | MA
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