Provider Demographics
NPI:1568643872
Name:BONAMICI, GREGG STUART (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:STUART
Last Name:BONAMICI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23601 FORD RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-1227
Mailing Address - Country:US
Mailing Address - Phone:313-565-8544
Mailing Address - Fax:313-565-3870
Practice Address - Street 1:23601 FORD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48128-1227
Practice Address - Country:US
Practice Address - Phone:313-565-8544
Practice Address - Fax:313-565-3870
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI137191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice