Provider Demographics
NPI:1790325884
Name:BONITA SONRISA DENTAL MSO
Entity Type:Organization
Organization Name:BONITA SONRISA DENTAL MSO
Other - Org Name:BONITA SONRISA DENTAL MSO
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEJANDRO
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-294-3725
Mailing Address - Street 1:1624 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-6948
Mailing Address - Country:US
Mailing Address - Phone:718-294-3725
Mailing Address - Fax:
Practice Address - Street 1:1624 DR MARTIN L KING JR BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-6948
Practice Address - Country:US
Practice Address - Phone:845-793-4469
Practice Address - Fax:718-450-8991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-07
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0455601OtherMSO
NY0455601OtherIPA
NY1223D0001XMedicaid
NY1700343233OtherIPA