Provider Demographics
NPI:1710191614
Name:BONIN, MARK TODD (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:TODD
Last Name:BONIN
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 1:17222 RED OAK DR
Mailing Address - Street 2:SUITE 107
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-2648
Mailing Address - Country:US
Mailing Address - Phone:281-440-3530
Mailing Address - Fax:281-440-5580
Practice Address - Street 1:17222 RED OAK DR
Practice Address - Street 2:SUITE 107
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-2648
Practice Address - Country:US
Practice Address - Phone:281-440-3530
Practice Address - Fax:281-440-5580
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX153871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice