Provider Demographics
NPI:1184980914
Name:FREDRIC L. BONINE, DDS, MS, PC
Entity type:Organization
Organization Name:FREDRIC L. BONINE, DDS, MS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDRIC
Authorized Official - Middle Name:L
Authorized Official - Last Name:BONINE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS, PC
Authorized Official - Phone:810-229-9180
Mailing Address - Street 1:6893 GRAND RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-9345
Mailing Address - Country:US
Mailing Address - Phone:810-229-9180
Mailing Address - Fax:810-229-1880
Practice Address - Street 1:6893 GRAND RIVER RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-9345
Practice Address - Country:US
Practice Address - Phone:810-229-9180
Practice Address - Fax:810-229-1880
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR. FREDRIC L. BONINE, DDS, MS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-05
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901012106305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1063440543OtherINDIVIDUAL NPI
MI1063440543OtherINDIVIDUAL NPI