Provider Demographics
NPI:1801132451
Name:BONILLA, DIEGO ALBERTO (DENTAL ASSISTANT)
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:ALBERTO
Last Name:BONILLA
Suffix:
Gender:M
Credentials:DENTAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2544 NW 98TH WAY
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-4960
Mailing Address - Country:US
Mailing Address - Phone:305-394-1578
Mailing Address - Fax:
Practice Address - Street 1:7305 NORTH MILITARY TRAIL
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33410
Practice Address - Country:US
Practice Address - Phone:561-422-7734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-28
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZDR 129942126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant