Healthcare Provider Details

I. General information

NPI: 1326298019
Provider Name (Legal Business Name): BONIFACIO L. HERRERA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3215 16 DE SEPTIEMBRE
JUAREZ CHIH
32140
MX

IV. Provider business mailing address

1120 WILL RAND DR.
EL PASO TX
79912-7620
US

V. Phone/Fax

Practice location:
  • Phone: 011526566145244
  • Fax:
Mailing address:
  • Phone: 915-449-8589
  • Fax: 915-833-8796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4181988
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: