Provider Demographics
NPI:1407010457
Name:BONNER, PAUL STEVEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:STEVEN
Last Name:BONNER
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 1:1 EUREKA CIRCLE
Mailing Address - Street 2:STE 103
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-2929
Mailing Address - Country:US
Mailing Address - Phone:940-691-5027
Mailing Address - Fax:
Practice Address - Street 1:1 EUREKA CIR
Practice Address - Street 2:SUITE 103
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2929
Practice Address - Country:US
Practice Address - Phone:940-691-5027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14022122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126799902Medicaid