Provider Demographics
NPI:1508342015
Name:RUSSELL BONHAM, KAYLA NICOLE (DDS)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:NICOLE
Last Name:RUSSELL BONHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3819 NE 45TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-5144
Mailing Address - Country:US
Mailing Address - Phone:206-524-6116
Mailing Address - Fax:
Practice Address - Street 1:3819 NE 45TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-5144
Practice Address - Country:US
Practice Address - Phone:206-524-6116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE608659651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice