1053582056 NPI number — CLETUS M. BONDS, III, DMD, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053582056 NPI number — CLETUS M. BONDS, III, DMD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLETUS M. BONDS, III, DMD, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053582056
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
80 W WELSH POOL RD
Provider Second Line Business Mailing Address:
SUITE 201 NORTH
Provider Business Mailing Address City Name:
EXTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19341-1233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-363-0809
Provider Business Mailing Address Fax Number:
610-363-0169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 W WELSH POOL RD
Provider Second Line Business Practice Location Address:
SUITE 201 NORTH
Provider Business Practice Location Address City Name:
EXTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19341-1233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-363-0809
Provider Business Practice Location Address Fax Number:
610-363-0169
Provider Enumeration Date:
03/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BONDS
Authorized Official First Name:
CLETUS
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
610-363-0809

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DS019857 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0005278070001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11833-2 . This is a "AMERICHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 118331 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2909 . This is a "DORAL DENTAL" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 110703 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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