Provider Demographics
NPI:1497822084
Name:BOMMARITO, KENNETH J (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:BOMMARITO
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 1:121 WATERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-9541
Mailing Address - Country:US
Mailing Address - Phone:352-735-0758
Mailing Address - Fax:352-735-0751
Practice Address - Street 1:121 WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-9541
Practice Address - Country:US
Practice Address - Phone:352-735-0758
Practice Address - Fax:352-735-0751
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL115681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice