Provider Demographics
NPI:1891719654
Name:MITCHELL, BONNY G (DDS)
Entity Type:Individual
Prefix:DR
First Name:BONNY
Middle Name:G
Last Name:MITCHELL
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 364
Mailing Address - Street 2:
Mailing Address - City:DAVIDSONVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21035-0364
Mailing Address - Country:US
Mailing Address - Phone:410-956-5555
Mailing Address - Fax:410-798-5165
Practice Address - Street 1:3102 DAVIDSONVILLE RD
Practice Address - Street 2:
Practice Address - City:DAVIDSONVILLE
Practice Address - State:MD
Practice Address - Zip Code:21035-1803
Practice Address - Country:US
Practice Address - Phone:410-956-5555
Practice Address - Fax:410-798-5165
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11985122300000X
MD7595122300000X
MD7646122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist