Healthcare Provider Details

I. General information

NPI: 1184837726
Provider Name (Legal Business Name): KODY JUDE BONIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16835 DEER CREEK DR STE 230
SPRING TX
77379-4895
US

IV. Provider business mailing address

7302 AUGUSTA PINES DR
SPRING TX
77389-2127
US

V. Phone/Fax

Practice location:
  • Phone: 281-376-7200
  • Fax:
Mailing address:
  • Phone: 281-376-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number15695
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: