Provider Demographics
NPI:1356541361
Name:ESTEBAN D. BONILLA DDS PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:ESTEBAN D. BONILLA DDS PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ESTEBAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BONILLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-980-2887
Mailing Address - Street 1:10745 RIVERSIDE DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602
Mailing Address - Country:US
Mailing Address - Phone:818-980-2887
Mailing Address - Fax:818-980-2807
Practice Address - Street 1:10745 RIVERSIDE DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:TOLUCA LAKE
Practice Address - State:CA
Practice Address - Zip Code:91602
Practice Address - Country:US
Practice Address - Phone:818-980-2887
Practice Address - Fax:818-980-2807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36135261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB36135OtherMEDI-CAL PIN