Provider Demographics
NPI:1326548454
Name:BONHAM, JULIE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:BONHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8960 SPRINGBROOK DR NW STE 150
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5810
Mailing Address - Country:US
Mailing Address - Phone:320-631-5653
Mailing Address - Fax:
Practice Address - Street 1:803 3RD ST. SE
Practice Address - Street 2:SUITE 330
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345
Practice Address - Country:US
Practice Address - Phone:206-315-6536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT95125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN467477400Medicaid