Provider Demographics
NPI:1366567380
Name:BONNICK, ANDREA MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:MARIE
Last Name:BONNICK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15150 PAWLEYS PL
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-5419
Mailing Address - Country:US
Mailing Address - Phone:202-865-1361
Mailing Address - Fax:202-865-3323
Practice Address - Street 1:2041 GEORGIA AVE NW
Practice Address - Street 2:SUITE 4C-46
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20060-0001
Practice Address - Country:US
Practice Address - Phone:202-865-1361
Practice Address - Fax:202-865-3323
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDN56261223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC4833OtherBLUECROSSBLUE SHIELD
DC0802270Medicaid
DC490772Medicare ID - Type Unspecified