Provider Demographics
NPI:1518023464
Name:BONVINO, TRUDY MARIE (DDS MS)
Entity Type:Individual
Prefix:
First Name:TRUDY
Middle Name:MARIE
Last Name:BONVINO
Suffix:
Gender:F
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14065 COMMERCE AVE NE
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-1436
Mailing Address - Country:US
Mailing Address - Phone:952-469-3333
Mailing Address - Fax:
Practice Address - Street 1:14065 COMMERCE AVE NE
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-1436
Practice Address - Country:US
Practice Address - Phone:952-469-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10859122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist