Provider Demographics
NPI:1205045382
Name:BONAVILLA, JOSEPH DAVIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:DAVIN
Last Name:BONAVILLA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 COOK RD
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-2126
Mailing Address - Country:US
Mailing Address - Phone:803-516-0777
Mailing Address - Fax:803-516-0577
Practice Address - Street 1:888 COOK RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-2126
Practice Address - Country:US
Practice Address - Phone:803-516-0777
Practice Address - Fax:803-516-0577
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC43051223E0200X
GADN0135071223E0200X
NY50-0519101223E0200X
WV35161223E0200X
VA04014116751223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics