Martin C Bonacorso, DDS
Individual provider Active NPI General Practice Dentistry · Baton Rouge, LA
NPI 1881702181 · NPPES record last updated Jul 8, 2007
Key facts
- NPI
- 1881702181
- Entity type
- Individual (NPI type 1)
- Primary specialty
- General Practice Dentistry 1223G0001X
- License
- LA1490 (LA)
- Practice address
- 563 Colonial Dr
Baton Rouge, LA 70806 - Phone
- (225) 924-6154
- Fax
- (225) 924-6154
- NPI assigned
- Aug 27, 2006
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in LA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20161018002089 | LA | Order and Referring Only - Dentist |
5395031835 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| LA1490 | LA | MD | General Practice Dentistry |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | LA1490 | LA | Yes |
Addresses
Primary practice location
563 Colonial Dr
Baton Rouge, LA 70806
Mailing address
563 Colonial Dr
Baton Rouge, LA 70806
Phone (225) 924-6154
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| LA1490 | Other | LA | DENTIST |
Other providers in Baton Rouge, LA
- Melissa Dawn Bolton
- Michael Todd Bolton
- Robert J Bolton
- Ronald L. Bombet
- Bon Guianza Therapy & Consultancy, LLC
- Britani Mouch Bonadona
- Jaina Elisabeth Bonanno
- Jeffrey Bonaventure
- Jennifer Bonaventure
- Justin Keith Bonaventure
All providers in Baton Rouge, LA · General Practice Dentistry in Louisiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 8, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.