Provider Demographics
NPI:1366567679
Name:EVERETT, BONNIE MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:MARIE
Last Name:EVERETT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:BONNIE
Other - Middle Name:MARIE
Other - Last Name:EVERETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1706 WILLOW ST STE A
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-5216
Mailing Address - Country:US
Mailing Address - Phone:408-264-8365
Mailing Address - Fax:408-445-2128
Practice Address - Street 1:1706 WILLOW ST STE A
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-5216
Practice Address - Country:US
Practice Address - Phone:408-264-8365
Practice Address - Fax:408-445-2128
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA035577122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist