Provider Demographics
NPI:1740321140
Name:JAVIER, BONIFACIO MORALES (DDS)
Entity type:Individual
Prefix:
First Name:BONIFACIO
Middle Name:MORALES
Last Name:JAVIER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 S VALLEY FORGE RD
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-4261
Mailing Address - Country:US
Mailing Address - Phone:215-368-1412
Mailing Address - Fax:215-368-0844
Practice Address - Street 1:850 S VALLEY FORGE RD
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-4261
Practice Address - Country:US
Practice Address - Phone:215-368-1412
Practice Address - Fax:215-368-0844
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-025787-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice