Provider Demographics
NPI:1528371465
Name:BONAVENTURA, CHRISTINA (DDS)
Entity type:Individual
Prefix:DR
First Name:CHRISTINA
Middle Name:
Last Name:BONAVENTURA
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 1:2 TAFT DR
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3128
Mailing Address - Country:US
Mailing Address - Phone:516-672-0005
Mailing Address - Fax:
Practice Address - Street 1:800 WOODBURY RD
Practice Address - Street 2:SUITE J
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-2503
Practice Address - Country:US
Practice Address - Phone:516-364-3388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-20
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054960122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist