Basic Information
| Provider Information | |||||||||
| NPI: | 1780888313 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONANNO | ||||||||
| FirstName: | SALVATORE | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1090 NORTHCHASE PKWY SE, SUITE 290 | ||||||||
| Address2: | KOOL SMILES SUPPORT SERVICES OFFICE/ NCDR, LLC | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789045665 | ||||||||
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| Practice Location | |||||||||
| Address1: | 137 HATHAWAY RD | ||||||||
| Address2: | |||||||||
| City: | NEW BEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027461304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9147470231 | ||||||||
| FaxNumber: | 9147471953 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2007 | ||||||||
| LastUpdateDate: | 05/03/2011 | ||||||||
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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 | 1223E0200X | 034267 | NY | Y | Dental Providers | Dentist | Endodontics |
No ID Information.