Provider Demographics
NPI:1891425328
Name:BONINE, BRANDON FREDRIC
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:FREDRIC
Last Name:BONINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3216 GOLF CLUB RD
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-9001
Mailing Address - Country:US
Mailing Address - Phone:517-861-0742
Mailing Address - Fax:
Practice Address - Street 1:1515 E. HOSPITAL DRIVE
Practice Address - Street 2:G1100 TOWSLEY CENTER
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109
Practice Address - Country:US
Practice Address - Phone:734-232-6048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist