MEDICARE: SCOTT C. BONIN D.D.S. A PROFESSIONAL DENAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1346806791
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCOTT C. BONIN D.D.S. A PROFESSIONAL DENAL CORPORATION

Provider Business Mailing Address
First Line	:	100 WINDSOR RIVER RD
Second Line	:
City	:	WINDSOR
State	:	CA
Zip	:	95492-9204
Country	:	US
Telephone Number	:	707-838-1400
Fax Number	:	707-838-1489

Provider Business Practice Location Address
First Line	:	100 WINDSOR RIVER RD
Second Line	:
City	:	WINDSOR
State	:	CA
Zip	:	95492-9204
Country	:	US
Telephone Number	:	707-838-1400
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SCOTT COLLIER BONIN
Credential	:	DDS
Telephone Number	:	619-733-7947

Provider Enumeration Date	:	05/11/2019
Last Update Date	:	07/22/2022

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