Provider Demographics
NPI:1467565630
Name:BONA, CHARLES C (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:C
Last Name:BONA
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 1:17636 W WESTWIND DR
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-1692
Mailing Address - Country:US
Mailing Address - Phone:847-856-0761
Mailing Address - Fax:
Practice Address - Street 1:7117 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-1450
Practice Address - Country:US
Practice Address - Phone:262-942-7000
Practice Address - Fax:262-942-7117
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4991-0151223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33751400Medicaid