Provider Demographics
NPI:1558498493
Name:BONOMO, MICHAEL A (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:BONOMO
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 1:519 W BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:QUAKERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18951-1215
Mailing Address - Country:US
Mailing Address - Phone:215-538-0211
Mailing Address - Fax:215-679-8038
Practice Address - Street 1:519 W BROAD STREET
Practice Address - Street 2:
Practice Address - City:QUAKERTOWN
Practice Address - State:PA
Practice Address - Zip Code:18951-1215
Practice Address - Country:US
Practice Address - Phone:215-538-0211
Practice Address - Fax:215-679-8038
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADSO28191122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist