Provider Demographics
NPI:1235353392
Name:BONNEY LAKE ORAL SURGERY
Entity Type:Organization
Organization Name:BONNEY LAKE ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:CORTESI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-863-2200
Mailing Address - Street 1:8412 MYERS RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-5112
Mailing Address - Country:US
Mailing Address - Phone:253-863-2200
Mailing Address - Fax:253-447-4968
Practice Address - Street 1:8412 MYERS RD
Practice Address - Street 2:SUITE 101
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-5112
Practice Address - Country:US
Practice Address - Phone:253-863-2200
Practice Address - Fax:253-447-4968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00008264122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty