Provider Demographics
NPI:1003270612
Name:BONNER, DOMINIQUE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOMINIQUE
Middle Name:
Last Name:BONNER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:DOMINIQUE
Other - Middle Name:
Other - Last Name:KNOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:9547A FAIRFAX BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4740
Mailing Address - Country:US
Mailing Address - Phone:703-520-9985
Mailing Address - Fax:
Practice Address - Street 1:9547A FAIRFAX BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4740
Practice Address - Country:US
Practice Address - Phone:703-520-9985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-09
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16313122300000X, 1223G0001X
VA0401415681122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019031088OtherIL DENTAL LICENSE #
VA0401415681OtherVA DENTAL LICENSE #
MD16313OtherMD DENTAL LICENSE #