Provider Demographics
NPI:1891067393
Name:BONILLAS TENORIO, FERNANDO (DDS)
Entity Type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:
Last Name:BONILLAS TENORIO
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 1:1042 MADDIE LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-2184
Mailing Address - Country:US
Mailing Address - Phone:619-623-3471
Mailing Address - Fax:
Practice Address - Street 1:ARIAS BERNAL 665 ZONA CENTRO
Practice Address - Street 2:
Practice Address - City:TIJUANA
Practice Address - State:BC
Practice Address - Zip Code:22000
Practice Address - Country:MX
Practice Address - Phone:52664-637-4287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-31
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ8968111223G0001X
ZZ45126871223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice