Provider Demographics
NPI:1306394176
Name:BONILLA, CARMEN
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:BONILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:DEL CARMEN LETICIA
Other - Last Name:BONILLA GARCIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:3200 S UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-2018
Mailing Address - Country:US
Mailing Address - Phone:954-262-7213
Mailing Address - Fax:954-262-7355
Practice Address - Street 1:3200 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2018
Practice Address - Country:US
Practice Address - Phone:954-262-7213
Practice Address - Fax:954-262-7355
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTEACHING PERMIT 5951223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics