Provider Demographics
NPI:1104540806
Name:DR B DENTISTRY PC
Entity type:Organization
Organization Name:DR B DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BONICELLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-350-5982
Mailing Address - Street 1:1701 38TH ST SW
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4499
Mailing Address - Country:US
Mailing Address - Phone:701-282-4044
Mailing Address - Fax:
Practice Address - Street 1:1701 38TH ST SW
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4499
Practice Address - Country:US
Practice Address - Phone:701-282-4044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental