Provider Demographics
NPI:1770744690
Name:BONICELLI, TANYA (DDS)
Entity type:Individual
Prefix:DR
First Name:TANYA
Middle Name:
Last Name:BONICELLI
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 1:4302 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3395
Mailing Address - Country:US
Mailing Address - Phone:701-277-3269
Mailing Address - Fax:701-277-4994
Practice Address - Street 1:4302 13TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3395
Practice Address - Country:US
Practice Address - Phone:701-277-3269
Practice Address - Fax:701-277-4994
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND20271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice