Provider Demographics
NPI:1346354164
Name:BOHNERT, MARK VICTOR (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:VICTOR
Last Name:BOHNERT
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 1:6020 SOUTHEASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-5611
Mailing Address - Country:US
Mailing Address - Phone:317-359-1754
Mailing Address - Fax:317-357-3663
Practice Address - Street 1:6020 SOUTHEASTERN AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203-5611
Practice Address - Country:US
Practice Address - Phone:317-359-1754
Practice Address - Fax:317-357-3663
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120079751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice