Provider Demographics
NPI:1578685855
Name:WHEATLEY, BONNIE J (DMD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:J
Last Name:WHEATLEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:BONNIE
Other - Middle Name:DANIELS
Other - Last Name:WHEATLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:100 HUBBARD RD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-2412
Mailing Address - Country:US
Mailing Address - Phone:859-745-1250
Mailing Address - Fax:859-744-1201
Practice Address - Street 1:100 HUBBARD RD
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-2412
Practice Address - Country:US
Practice Address - Phone:859-745-1250
Practice Address - Fax:859-744-1201
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2521223X0400X
KY42041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60042041Medicaid