Provider Demographics
NPI:1952538159
Name:BONNER, LAURA L (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:L
Last Name:BONNER
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 S METRO PKWY
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8530
Mailing Address - Country:US
Mailing Address - Phone:479-899-6400
Mailing Address - Fax:479-358-1454
Practice Address - Street 1:402 S METRO PKWY
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8530
Practice Address - Country:US
Practice Address - Phone:479-899-6400
Practice Address - Fax:479-358-1454
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN-99231223G0001X
AR40161223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR209905608Medicaid