MEDICARE: BONNEY LAKE DENTAL CENTER

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	:	1477783199
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BONNEY LAKE DENTAL CENTER

Provider Business Mailing Address
First Line	:	9925 214TH AVE E STE A
Second Line	:
City	:	BONNEY LAKE
State	:	WA
Zip	:	98391-3910
Country	:	US
Telephone Number	:	253-863-4594
Fax Number	:	253-863-5061

Provider Business Practice Location Address
First Line	:	9925 214TH AVE E STE A
Second Line	:
City	:	BONNEY LAKE
State	:	WA
Zip	:	98391-3910
Country	:	US
Telephone Number	:	253-863-4594
Fax Number	:	253-863-5061

Authorized Official
Title or Position	:	DENTIST
Name	:	MRS. DELIA CONSTANTIN
Credential	:	DDS
Telephone Number	:	253-863-4594

Provider Enumeration Date	:	07/15/2009
Last Update Date	:	07/15/2009

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9925 214TH AVE E , SUITE A
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BONNEY LAKE, WA
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Practice Location Address:

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1457580920 — DR. DELIA CONSTANTIN DDS
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98391-3910

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