Provider Demographics
NPI:1881702181
Name:BONACORSO, MARTIN C (DDS)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:C
Last Name:BONACORSO
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 1:563 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806
Mailing Address - Country:US
Mailing Address - Phone:225-924-6154
Mailing Address - Fax:225-924-1058
Practice Address - Street 1:563 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806
Practice Address - Country:US
Practice Address - Phone:225-924-6154
Practice Address - Fax:225-924-6154
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA14901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LALA1490OtherDENTIST