Provider Demographics
NPI:1659992865
Name:JUSTIN K BONAVENTURE DENTAL OFFICES, LLC
Entity Type:Organization
Organization Name:JUSTIN K BONAVENTURE DENTAL OFFICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BONAVENTURE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-936-3933
Mailing Address - Street 1:13702 COURSEY BLVD, BLDG 10, STE C
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-1370
Mailing Address - Country:US
Mailing Address - Phone:225-936-3933
Mailing Address - Fax:
Practice Address - Street 1:13702 COURSEY BLVD, BLDG 10, STE C
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-1370
Practice Address - Country:US
Practice Address - Phone:225-936-3933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty