Provider Demographics
NPI:1245491471
Name:BONNESS FAMILY DENTISTRY PC
Entity type:Organization
Organization Name:BONNESS FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:BONNESS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-821-1130
Mailing Address - Street 1:10701 ALLIANCE DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:CAMBY
Mailing Address - State:IN
Mailing Address - Zip Code:46113-8836
Mailing Address - Country:US
Mailing Address - Phone:317-821-1130
Mailing Address - Fax:317-821-1145
Practice Address - Street 1:10701 ALLIANCE DR
Practice Address - Street 2:SUITE F
Practice Address - City:CAMBY
Practice Address - State:IN
Practice Address - Zip Code:46113-8836
Practice Address - Country:US
Practice Address - Phone:317-821-1130
Practice Address - Fax:317-821-1145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010300A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200453220Medicaid