Provider Demographics
NPI:1437795093
Name:CUSTOM DENTAL OF BONHAM PLLC
Entity Type:Organization
Organization Name:CUSTOM DENTAL OF BONHAM PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BRYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:GATES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-227-6100
Mailing Address - Street 1:2016 N STATE HIGHWAY 121
Mailing Address - Street 2:
Mailing Address - City:BONHAM
Mailing Address - State:TX
Mailing Address - Zip Code:75418-2339
Mailing Address - Country:US
Mailing Address - Phone:214-616-1574
Mailing Address - Fax:
Practice Address - Street 1:2016 STATE HIGHWAY 121 N
Practice Address - Street 2:
Practice Address - City:BONHAM
Practice Address - State:TX
Practice Address - Zip Code:75418
Practice Address - Country:US
Practice Address - Phone:903-227-6576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-19
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental