Provider Demographics
NPI:1457521312
Name:BONILLA, JAVIER E (DDS)
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:E
Last Name:BONILLA
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 1:17140 ROYAL PALM BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-2312
Mailing Address - Country:US
Mailing Address - Phone:954-217-8411
Mailing Address - Fax:951-217-9243
Practice Address - Street 1:17140 ROYAL PALM BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-2312
Practice Address - Country:US
Practice Address - Phone:954-217-8411
Practice Address - Fax:951-217-9243
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 17089122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist