Provider Demographics
NPI:1457899940
Name:ODIRILE, BONOLO BLESSED (BDS)
Entity Type:Individual
Prefix:
First Name:BONOLO
Middle Name:BLESSED
Last Name:ODIRILE
Suffix:
Gender:F
Credentials:BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5813 ALBRIGHT CT
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-5045
Mailing Address - Country:US
Mailing Address - Phone:267-270-0068
Mailing Address - Fax:
Practice Address - Street 1:2101 MIDLAND DRIVE
Practice Address - Street 2:#14
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701
Practice Address - Country:US
Practice Address - Phone:423-699-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX326171223X0400X
VA04014154481223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics