Provider Demographics
NPI:1922521715
Name:BONASSO, ALESSANDRA MICHELE (DDS)
Entity Type:Individual
Prefix:
First Name:ALESSANDRA
Middle Name:MICHELE
Last Name:BONASSO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:ALESSANDRA
Other - Middle Name:MICHELE
Other - Last Name:PACILLI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:2221 E BIJOU ST STE 100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-8009
Mailing Address - Country:US
Mailing Address - Phone:719-576-1850
Mailing Address - Fax:719-955-3470
Practice Address - Street 1:1253 W PRATT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21223-2684
Practice Address - Country:US
Practice Address - Phone:410-727-4746
Practice Address - Fax:410-727-6767
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16471122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD16471OtherSTATE LICENSE
DC016290051Medicaid
MD126457500Medicaid