Provider Demographics
NPI:1144217985
Name:BONNET, BRYAN EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:EDWARD
Last Name:BONNET
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12195 S YUKON AVE
Mailing Address - Street 2:
Mailing Address - City:GLENPOOL
Mailing Address - State:OK
Mailing Address - Zip Code:74033-6621
Mailing Address - Country:US
Mailing Address - Phone:918-322-9445
Mailing Address - Fax:
Practice Address - Street 1:12195 S YUKON AVE
Practice Address - Street 2:
Practice Address - City:GLENPOOL
Practice Address - State:OK
Practice Address - Zip Code:74033-6621
Practice Address - Country:US
Practice Address - Phone:918-322-9445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5456122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100255520AMedicaid