Provider Demographics
NPI:1871651026
Name:BOONE, BONNI MARIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:BONNI
Middle Name:MARIA
Last Name:BOONE
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 1:734 E IRELAND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-2662
Mailing Address - Country:US
Mailing Address - Phone:574-299-9300
Mailing Address - Fax:574-299-9853
Practice Address - Street 1:734 E IRELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2662
Practice Address - Country:US
Practice Address - Phone:574-299-9300
Practice Address - Fax:574-299-9853
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120090041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice