Basic Information
| Provider Information | |||||||||
| NPI: | 1083055164 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONILLA | ||||||||
| FirstName: | RAUL | ||||||||
| MiddleName: | JOSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3750 COMMERCIAL AVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782213117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103343711 | ||||||||
| FaxNumber: | 2102717208 | ||||||||
| Practice Location | |||||||||
| Address1: | 3750 COMMERCIAL AVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782213117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103343700 | ||||||||
| FaxNumber: | 2102717208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2013 | ||||||||
| LastUpdateDate: | 07/17/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 29330 | TX | Y | Dental Providers | Dentist | General Practice |
No ID Information.