MEDICARE: MRS. KATHLEEN SUSAN BONILLA RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	12610	TX

General Provider Information

NPI Number	:	1962533505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHLEEN SUSAN BONILLA RDH

Provider Business Mailing Address
First Line	:	4185 SICILY DR
Second Line	:
City	:	FRISCO
State	:	TX
Zip	:	75034-6660
Country	:	US
Telephone Number	:	972-987-5587
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 S DENTON TAP RD
Second Line	:	SUITE #100
City	:	COPPELL
State	:	TX
Zip	:	75019-3297
Country	:	US
Telephone Number	:	469-635-1105
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	07/08/2007

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