Provider Demographics
NPI:1003565110
Name:BONSALL, ALLISON KATHRYN
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:KATHRYN
Last Name:BONSALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 MONTEREY AVE APT D
Mailing Address - Street 2:
Mailing Address - City:PACIFIC GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:93950-2862
Mailing Address - Country:US
Mailing Address - Phone:610-416-9890
Mailing Address - Fax:
Practice Address - Street 1:2440 FREMONT ST STE 211
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-6850
Practice Address - Country:US
Practice Address - Phone:610-416-9890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-23
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1088501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program