Provider Demographics
NPI:1770562415
Name:PRUITT, BONITA LYNN (DDS)
Entity type:Individual
Prefix:DR
First Name:BONITA
Middle Name:LYNN
Last Name:PRUITT
Suffix:
Gender:F
Credentials:DDS
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Other - Credentials:
Mailing Address - Street 1:US ARMY DENTAL ACTIVITY ATTN CREDENTIALS COORDINATOR
Mailing Address - Street 2:10205 NORTH RIVA RIDGE LOOP
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13603-5005
Mailing Address - Country:US
Mailing Address - Phone:315-772-4342
Mailing Address - Fax:315-772-9692
Practice Address - Street 1:US ARMY DENTAL ACTIVITY ATTN CREDENTIALS COORDINATOR
Practice Address - Street 2:10205 NORTH RIVA RIDGE LOOP
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13603-5005
Practice Address - Country:US
Practice Address - Phone:315-772-4342
Practice Address - Fax:315-772-9692
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX149771223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN