Provider Demographics
NPI:1952605560
Name:BONHAM, ROBERT LUSK (DDS (DENTIST))
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LUSK
Last Name:BONHAM
Suffix:
Gender:M
Credentials:DDS (DENTIST)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 LINCOLN WAY EAST
Mailing Address - Street 2:
Mailing Address - City:SO. BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601
Mailing Address - Country:US
Mailing Address - Phone:574-287-3300
Mailing Address - Fax:574-287-3301
Practice Address - Street 1:1222 L.W.E.
Practice Address - Street 2:
Practice Address - City:SO. BEND
Practice Address - State:IN
Practice Address - Zip Code:46601
Practice Address - Country:US
Practice Address - Phone:574-287-3300
Practice Address - Fax:574-287-3301
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-23
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN6474122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist