Provider Demographics
NPI:1356451405
Name:DRS BONIFANT & BROOKRESON DDS PLLC
Entity Type:Organization
Organization Name:DRS BONIFANT & BROOKRESON DDS PLLC
Other - Org Name:BRIARWOOD DENTAL CENTER PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:W
Authorized Official - Last Name:BONIFANT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-263-3367
Mailing Address - Street 1:1003 SUSHRUTA DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401
Mailing Address - Country:US
Mailing Address - Phone:304-263-3367
Mailing Address - Fax:304-263-1634
Practice Address - Street 1:1003 SUSHRUTA DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401
Practice Address - Country:US
Practice Address - Phone:304-263-3367
Practice Address - Fax:304-263-1634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV850292OtherUNITED CONCORDIA