Provider Demographics
NPI:1689689564
Name:BONNY, LYLE I (DDS)
Entity Type:Individual
Prefix:DR
First Name:LYLE
Middle Name:I
Last Name:BONNY
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 1:2402 W YAKIMA AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2833
Mailing Address - Country:US
Mailing Address - Phone:509-452-3731
Mailing Address - Fax:
Practice Address - Street 1:112 S 39TH ST
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-1450
Practice Address - Country:US
Practice Address - Phone:509-248-4957
Practice Address - Fax:509-575-5436
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000061961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice