Provider Demographics
NPI:1558351866
Name:PADWA, BONNIE L (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:L
Last Name:PADWA
Suffix:
Gender:F
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:HU-158
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-6259
Mailing Address - Fax:617-738-1657
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:HU-158
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-6259
Practice Address - Fax:617-738-1657
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA75473204E00000X
MA170081223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ13074OtherBCBS MA
MA730778OtherTUFTS HEALTH PLAN
MA3101207Medicaid
MAJ13074Medicare ID - Type Unspecified
MA730778OtherTUFTS HEALTH PLAN
MA3101207Medicaid