Provider Demographics
NPI:1811549918
Name:BONANNO, DAVID RICHARD (DMD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RICHARD
Last Name:BONANNO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11717 BERNARDO PLAZA CT STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2419
Mailing Address - Country:US
Mailing Address - Phone:858-673-1633
Mailing Address - Fax:858-673-0093
Practice Address - Street 1:11717 BERNARDO PLAZA CT STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2419
Practice Address - Country:US
Practice Address - Phone:858-673-1633
Practice Address - Fax:858-673-0093
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002039791223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice