Provider Demographics
NPI:1205304375
Name:BONITA SPRINGS EDC MANAGEMENT LLC
Entity type:Organization
Organization Name:BONITA SPRINGS EDC MANAGEMENT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OBENG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-981-4136
Mailing Address - Street 1:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:BOYS TOWN
Mailing Address - State:NE
Mailing Address - Zip Code:68010-0788
Mailing Address - Country:US
Mailing Address - Phone:402-658-4687
Mailing Address - Fax:402-597-3643
Practice Address - Street 1:8553 W LINEBAUGH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-3731
Practice Address - Country:US
Practice Address - Phone:813-926-9228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BONITA SPRINGS EDC MANAGEMENT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-07
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty