Provider Demographics
NPI:1558463240
Name:BONACCI, FRED J (DMD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:J
Last Name:BONACCI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:672 S RIVER ST STE 209
Mailing Address - Street 2:
Mailing Address - City:PLAINS
Mailing Address - State:PA
Mailing Address - Zip Code:18705-1034
Mailing Address - Country:US
Mailing Address - Phone:570-846-2300
Mailing Address - Fax:
Practice Address - Street 1:672 S RIVER ST STE 209
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:PA
Practice Address - Zip Code:18705-1034
Practice Address - Country:US
Practice Address - Phone:570-846-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA201451223P0300X
PADS031389L1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics