Provider Demographics
NPI:1760719124
Name:BONVINO, ALYSIA MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALYSIA
Middle Name:MARIE
Last Name:BONVINO
Suffix:
Gender:F
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:PO BOX 259
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:NY
Mailing Address - Zip Code:13084
Mailing Address - Country:US
Mailing Address - Phone:315-677-3113
Mailing Address - Fax:315-677-3114
Practice Address - Street 1:2509 RT 11
Practice Address - Street 2:MAHER BUILDING
Practice Address - City:LAFAYETTE
Practice Address - State:NY
Practice Address - Zip Code:13084-9739
Practice Address - Country:US
Practice Address - Phone:315-677-3113
Practice Address - Fax:315-677-3114
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0480931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice