Provider Demographics
NPI:1023535820
Name:BONAVILLA, DENNIS
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:BONAVILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34859 FREDERICK ST STE 112
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-7007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34859 FREDERICK STREET
Practice Address - Street 2:SUITE 112
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595
Practice Address - Country:US
Practice Address - Phone:951-897-0770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic