Provider Demographics
NPI:1992929665
Name:BONILLA, TREVOR S (DDS, MS, PA)
Entity type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:S
Last Name:BONILLA
Suffix:
Gender:M
Credentials:DDS, MS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 W. STATE HIGHWAY 121
Mailing Address - Street 2:SUITE 105
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019
Mailing Address - Country:US
Mailing Address - Phone:972-459-6800
Mailing Address - Fax:972-459-9300
Practice Address - Street 1:137 W. STATE HIGHWAY 121
Practice Address - Street 2:SUITE 105
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019
Practice Address - Country:US
Practice Address - Phone:972-459-6800
Practice Address - Fax:972-459-9300
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX197521223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics