Provider Demographics
NPI:1720006661
Name:CHRISTOPHER E. BONACCI DDS MD PC
Entity Type:Organization
Organization Name:CHRISTOPHER E. BONACCI DDS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:BONACCI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MD
Authorized Official - Phone:703-255-9400
Mailing Address - Street 1:361 MAPLE AVE W
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4304
Mailing Address - Country:US
Mailing Address - Phone:703-255-9400
Mailing Address - Fax:
Practice Address - Street 1:361 MAPLE AVE W
Practice Address - Street 2:SUITE 200
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4304
Practice Address - Country:US
Practice Address - Phone:703-255-9400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057525261QS0112X
VA0401102631261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA286159Medicare UPIN