MEDICARE: DR. DAVID TODD BANOONI DDS

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	122300000X	Dentist	2901022615	MI

General Provider Information

NPI Number	:	1629569900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID TODD BANOONI DDS

Provider Business Mailing Address
First Line	:	1971 LONG LAKE SHORE DR
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-1238
Country	:	US
Telephone Number	:	248-978-7962
Fax Number	:

Provider Business Practice Location Address
First Line	:	155 N CANTON CENTER RD
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48187-2901
Country	:	US
Telephone Number	:	734-844-1300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2018
Last Update Date	:	05/23/2018

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