Provider Demographics
NPI:1235655010
Name:BONIFATTO, PETER STEPHEN (DMD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:STEPHEN
Last Name:BONIFATTO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 HANCOCK AVE APT 14
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-6804
Mailing Address - Country:US
Mailing Address - Phone:702-588-3499
Mailing Address - Fax:
Practice Address - Street 1:24218 VALENCIA BLVD
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-5391
Practice Address - Country:US
Practice Address - Phone:661-288-0288
Practice Address - Fax:661-286-9925
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1017321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice