Provider Demographics
NPI:1386203693
Name:BONTRAGER, KALYSSA MAE (DDS)
Entity type:Individual
Prefix:DR
First Name:KALYSSA
Middle Name:MAE
Last Name:BONTRAGER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KALEY
Other - Middle Name:MAE
Other - Last Name:BONTRAGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 183
Mailing Address - Street 2:
Mailing Address - City:STROH
Mailing Address - State:IN
Mailing Address - Zip Code:46789-0183
Mailing Address - Country:US
Mailing Address - Phone:260-580-5246
Mailing Address - Fax:
Practice Address - Street 1:612 S DETROIT ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-2314
Practice Address - Country:US
Practice Address - Phone:260-463-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013143A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist