MEDICARE: DR. MILES HUGH BONOM 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	5329	CT

General Provider Information

NPI Number	:	1811998339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MILES HUGH BONOM DDS

Provider Business Mailing Address
First Line	:	838 HIGH RIDGE RD
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06905-1913
Country	:	US
Telephone Number	:	203-322-5153
Fax Number	:	203-329-9151

Provider Business Practice Location Address
First Line	:	838 HIGH RIDGE RD
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06905-1913
Country	:	US
Telephone Number	:	203-322-5153
Fax Number	:	203-329-9151

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

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	04/05/2018

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