Provider Demographics
NPI:1629569900
Name:BANOONI, DAVID TODD (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:TODD
Last Name:BANOONI
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 1:1971 LONG LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-1238
Mailing Address - Country:US
Mailing Address - Phone:248-978-7962
Mailing Address - Fax:
Practice Address - Street 1:155 N CANTON CENTER RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2901
Practice Address - Country:US
Practice Address - Phone:734-844-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901022615122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist