Provider Demographics
NPI:1699877860
Name:MISIAK, BONNIE (DDS)
Entity type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:
Last Name:MISIAK
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 1:115 K D REVELL RD
Mailing Address - Street 2:
Mailing Address - City:WAUCHULA
Mailing Address - State:FL
Mailing Address - Zip Code:33873-2051
Mailing Address - Country:US
Mailing Address - Phone:863-773-4161
Mailing Address - Fax:
Practice Address - Street 1:115 K D REVELL RD
Practice Address - Street 2:
Practice Address - City:WAUCHULA
Practice Address - State:FL
Practice Address - Zip Code:33873-2051
Practice Address - Country:US
Practice Address - Phone:863-773-4161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN166411223D0001X
FLDH17043124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDH17043OtherDH LICENSE
FL027924211Medicaid
FLDN16641OtherDDS LICENSE