Active NPI
Bonita Lynn Pruitt, DDS
- Pediatric Dentistry
- Fort Drum, NY
National Provider Identifier
1770562415
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Dentistry
- License
- 14977
- Practice address
- US Army Dental Activity Attn Credentials Coordinator
10205 North Riva Ridge Loop
Fort Drum, NY 13603-5005 - Phone
- (315) 772-4342
- Fax
- (315) 772-9692
- NPI assigned
- Jan 11, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Dentistry | 1223P0221X | 14977 | TX | Primary |
Addresses
Primary practice location
US Army Dental Activity Attn Credentials Coordinator
10205 North Riva Ridge Loop
Fort Drum, NY 13603-5005
Mailing address
US Army Dental Activity Attn Credentials Coordinator
10205 North Riva Ridge Loop
Fort Drum, NY 13603-5005
Phone (315) 772-4342
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 14977 | TX | MD | Addiction (Substance Use Disorder) Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1136937600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1770562415",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "US ARMY DENTAL ACTIVITY ATTN CREDENTIALS COORDINATOR",
"address_2": "10205 NORTH RIVA RIDGE LOOP",
"city": "FORT DRUM",
"state": "NY",
"postal_code": "136035005",
"telephone_number": "315-772-4342",
"fax_number": "315-772-9692"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "US ARMY DENTAL ACTIVITY ATTN CREDENTIALS COORDINATOR",
"address_2": "10205 NORTH RIVA RIDGE LOOP",
"city": "FORT DRUM",
"state": "NY",
"postal_code": "136035005",
"telephone_number": "315-772-4342",
"fax_number": "315-772-9692"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PRUITT",
"first_name": "BONITA",
"middle_name": "LYNN",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-01-11",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "TX",
"license": "14977",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fort Drum, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.