Healthcare Provider Details

I. General information

NPI: 1891067393
Provider Name (Legal Business Name): FERNANDO BONILLAS TENORIO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2012
Last Update Date: 01/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ARIAS BERNAL 665 ZONA CENTRO
TIJUANA BC
22000
MX

IV. Provider business mailing address

1042 MADDIE LN
SAN DIEGO CA
92154-2184
US

V. Phone/Fax

Practice location:
  • Phone: 526646374287
  • Fax:
Mailing address:
  • Phone: 619-623-3471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number896811
License Number StateZZ
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4512687
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: