Provider Demographics
NPI:1164436705
Name:BONIFACIO, JONAR R (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONAR
Middle Name:R
Last Name:BONIFACIO
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 1:1620 ALPINE BLVD
Mailing Address - Street 2:#121
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-1102
Mailing Address - Country:US
Mailing Address - Phone:619-445-8896
Mailing Address - Fax:619-445-7339
Practice Address - Street 1:1620 ALPINE BLVD
Practice Address - Street 2:#121
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-1102
Practice Address - Country:US
Practice Address - Phone:619-445-8896
Practice Address - Fax:619-445-7339
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47454122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist