Provider Demographics
NPI:1114099348
Name:BONNER, LECHANDRE
Entity Type:Individual
Prefix:DR
First Name:LECHANDRE
Middle Name:
Last Name:BONNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LECHANDRE
Other - Middle Name:
Other - Last Name:WADLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2019 CLOVERCROFT RD NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-7178
Mailing Address - Country:US
Mailing Address - Phone:706-627-9079
Mailing Address - Fax:
Practice Address - Street 1:425 BARRETT PKWY STE 4060
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-4949
Practice Address - Country:US
Practice Address - Phone:678-905-6300
Practice Address - Fax:678-905-6301
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0124351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000946536LMedicaid
GA000946536APMedicaid
GA000946536CMedicaid