Provider Demographics
NPI:1376873828
Name:BONAVENTURE, JUSTIN KEITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:KEITH
Last Name:BONAVENTURE
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 1:13702 COURSEY BLVD. BLDG 10, STE C
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817
Mailing Address - Country:US
Mailing Address - Phone:225-925-2118
Mailing Address - Fax:
Practice Address - Street 1:13702 COURSEY BLVD. BLDG 10, STE C
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817
Practice Address - Country:US
Practice Address - Phone:225-925-2118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-06
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA59581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice