Provider Demographics
NPI:1437360039
Name:BONACORSI, ANTHONY OLIVER (D,D,S,)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:OLIVER
Last Name:BONACORSI
Suffix:
Gender:M
Credentials:D,D,S,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1748
Mailing Address - Country:US
Mailing Address - Phone:203-597-9044
Mailing Address - Fax:203-597-8860
Practice Address - Street 1:80 PHOENIX AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-1418
Practice Address - Country:US
Practice Address - Phone:203-756-8021
Practice Address - Fax:203-596-9038
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0038591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice