Provider Demographics
NPI:1336142868
Name:BONAVENTURA, MARINA CELESTE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARINA
Middle Name:CELESTE
Last Name:BONAVENTURA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 ANNS CT
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27205-7732
Mailing Address - Country:US
Mailing Address - Phone:336-318-1014
Mailing Address - Fax:
Practice Address - Street 1:303 ROSS ST
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-5419
Practice Address - Country:US
Practice Address - Phone:336-318-1014
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC60051223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
U69433Medicare UPIN