Basic Information
Provider Information
NPI: 1497827174
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GILL
FirstName: BONANN
MiddleName: GIFFORD
NamePrefix:  
NameSuffix:  
Credential: RDH
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 915 E 40TH ST
Address2:  
City: BROOKLYN
State: NY
PostalCode: 112103509
CountryCode: US
TelephoneNumber: 7183455000
FaxNumber: 7183466747
Practice Location
Address1: 592 ROCKAWAY AVE
Address2:  
City: BROOKLYN
State: NY
PostalCode: 112125539
CountryCode: US
TelephoneNumber: 7183455000
FaxNumber: 7183466747
Other Information
ProviderEnumerationDate: 11/15/2006
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
124Q00000X021860NYY Dental ProvidersDental Hygienist 

No ID Information.


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