Provider Demographics
NPI:1912265133
Name:BONVALLET DENTAL, PC
Entity Type:Organization
Organization Name:BONVALLET DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BONVALLET
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:815-234-4211
Mailing Address - Street 1:132 N WALNUT ST
Mailing Address - Street 2:PO BOX 432
Mailing Address - City:BYRON
Mailing Address - State:IL
Mailing Address - Zip Code:61010-8807
Mailing Address - Country:US
Mailing Address - Phone:815-234-4211
Mailing Address - Fax:
Practice Address - Street 1:132 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:IL
Practice Address - Zip Code:61010-8807
Practice Address - Country:US
Practice Address - Phone:815-234-4211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027531261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental