Provider Demographics
NPI:1568656692
Name:BONEVILLE, RICHARD SAMUEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:SAMUEL
Last Name:BONEVILLE
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 1:2001 MARCUS AVE
Mailing Address - Street 2:N 205
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1011
Mailing Address - Country:US
Mailing Address - Phone:516-354-4900
Mailing Address - Fax:516-354-1492
Practice Address - Street 1:2001 MARCUS AVE
Practice Address - Street 2:N 205
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1011
Practice Address - Country:US
Practice Address - Phone:516-354-4900
Practice Address - Fax:516-354-1492
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030121-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice