Provider Demographics
NPI:1629113790
Name:FUNK, BONNIE LYNNE (DMD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:LYNNE
Last Name:FUNK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S WHITE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-6112
Mailing Address - Country:US
Mailing Address - Phone:928-537-5005
Mailing Address - Fax:928-537-5017
Practice Address - Street 1:401 S WHITE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-6112
Practice Address - Country:US
Practice Address - Phone:928-537-5005
Practice Address - Fax:928-537-5017
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ54031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0497391OtherBLUECROSS BLUESHIELD