Provider Demographics
NPI:1346893468
Name:GONZALEZ BONIFACIO, JUAN JOSE
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:JOSE
Last Name:GONZALEZ BONIFACIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:488 S BURLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-3006
Mailing Address - Country:US
Mailing Address - Phone:213-318-1079
Mailing Address - Fax:
Practice Address - Street 1:5162 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-3932
Practice Address - Country:US
Practice Address - Phone:323-510-5920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA92496126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant