Healthcare Provider Details

I. General information

NPI: 1285760900
Provider Name (Legal Business Name): BONNY GAYLE GRIGOR DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BONNY GRIGOR HERNANDEZ DMD

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6015 LOHMANS FORD RD SUITE103
LAGO VISTA TX
78645-5105
US

IV. Provider business mailing address

6015 LOHMANS FORD RD SUITE103
LAGO VISTA TX
78645-5105
US

V. Phone/Fax

Practice location:
  • Phone: 512-267-5200
  • Fax:
Mailing address:
  • Phone: 512-267-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number25278
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: