Provider Demographics
NPI:1114432531
Name:BONANZA DENTAL PARTNERS
Entity Type:Organization
Organization Name:BONANZA DENTAL PARTNERS
Other - Org Name:BOCA DENTAL AND BRACES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:J
Authorized Official - Last Name:CAZZALY
Authorized Official - Suffix:
Authorized Official - Credentials:DIANA CAZZALY
Authorized Official - Phone:702-960-4484
Mailing Address - Street 1:556 N EASTERN AVE STE I
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89101-3453
Mailing Address - Country:US
Mailing Address - Phone:702-960-4484
Mailing Address - Fax:702-987-3040
Practice Address - Street 1:556 N EASTERN AVE STE I
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-3453
Practice Address - Country:US
Practice Address - Phone:702-960-4484
Practice Address - Fax:702-987-3040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-07
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty