Provider Demographics
NPI:1497827174
Name:GILL, BONANN GIFFORD (RDH)
Entity Type:Individual
Prefix:
First Name:BONANN
Middle Name:GIFFORD
Last Name:GILL
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 E 40TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-3509
Mailing Address - Country:US
Mailing Address - Phone:718-345-5000
Mailing Address - Fax:718-346-6747
Practice Address - Street 1:592 ROCKAWAY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-5539
Practice Address - Country:US
Practice Address - Phone:718-345-5000
Practice Address - Fax:718-346-6747
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021860124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist