Provider Demographics
NPI:1427225754
Name:BONURA, JACK J (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:J
Last Name:BONURA
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 1:1931 CANBY RD
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-0338
Mailing Address - Country:US
Mailing Address - Phone:530-222-1000
Mailing Address - Fax:530-222-1292
Practice Address - Street 1:1931 CANBY RD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-0338
Practice Address - Country:US
Practice Address - Phone:530-222-1000
Practice Address - Fax:530-222-1292
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA303691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice