Basic Information
| Provider Information | |||||||||
| NPI: | 1437360039 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONACORSI | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | OLIVER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D,D,S, | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1302 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067061748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035979044 | ||||||||
| FaxNumber: | 2035978860 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 PHOENIX AVE | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067021418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037568021 | ||||||||
| FaxNumber: | 2035969038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 02/29/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 003859 | CT | Y | Dental Providers | Dentist | General Practice |
No ID Information.