Provider Demographics
NPI:1497479877
Name:BONOLA, JACOB ANTHONY (DMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ANTHONY
Last Name:BONOLA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 BARRINGTON DR
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76262-9004
Mailing Address - Country:US
Mailing Address - Phone:817-915-0888
Mailing Address - Fax:
Practice Address - Street 1:100 FORREST TER
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-6804
Practice Address - Country:US
Practice Address - Phone:903-938-8315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390271223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty