Provider Demographics
NPI:1578236527
Name:BONNER ORAL SURGERY, PLLC
Entity Type:Organization
Organization Name:BONNER ORAL SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:325-437-3100
Mailing Address - Street 1:4 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-5289
Mailing Address - Country:US
Mailing Address - Phone:325-437-3100
Mailing Address - Fax:325-437-3199
Practice Address - Street 1:4 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-5289
Practice Address - Country:US
Practice Address - Phone:325-437-3100
Practice Address - Fax:325-437-3199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty