Provider Demographics
NPI:1376763201
Name:BONGIOVI, MICHELLE (DMD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BONGIOVI
Suffix:
Gender:F
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:PSC 78 BOX 57
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96326-0001
Mailing Address - Country:US
Mailing Address - Phone:315-225-3852
Mailing Address - Fax:
Practice Address - Street 1:USAF
Practice Address - Street 2:PSC 78
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96326-0001
Practice Address - Country:US
Practice Address - Phone:315-225-3852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV30701223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics