Provider Demographics
NPI:1477783199
Name:BONNEY LAKE DENTAL CENTER
Entity Type:Organization
Organization Name:BONNEY LAKE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONSTANTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-863-4594
Mailing Address - Street 1:9925 214TH AVE E STE A
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-3910
Mailing Address - Country:US
Mailing Address - Phone:253-863-4594
Mailing Address - Fax:253-863-5061
Practice Address - Street 1:9925 214TH AVE E STE A
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-3910
Practice Address - Country:US
Practice Address - Phone:253-863-4594
Practice Address - Fax:253-863-5061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-15
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty