Provider Demographics
NPI:1275947228
Name:BONILLA, DIEGO (DDS)
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:
Last Name:BONILLA
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 1:5202 TEXANA DR APT 536
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-3793
Mailing Address - Country:US
Mailing Address - Phone:817-937-1411
Mailing Address - Fax:
Practice Address - Street 1:5202 TEXANA DR APT 536
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-3793
Practice Address - Country:US
Practice Address - Phone:817-937-1411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX300221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice