Provider Demographics
NPI:1396873717
Name:BONAHOOM, ROBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:BONAHOOM
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 1:1291 E HILLSDALE BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FOSTER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94404-1220
Mailing Address - Country:US
Mailing Address - Phone:650-574-3611
Mailing Address - Fax:650-574-1764
Practice Address - Street 1:1291 E HILLSDALE BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:FOSTER CITY
Practice Address - State:CA
Practice Address - Zip Code:94404-1220
Practice Address - Country:US
Practice Address - Phone:650-574-3611
Practice Address - Fax:650-574-1764
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22785122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist