Provider Demographics
NPI:1063440543
Name:BONINE, FREDRIC L (DDS, MS, PC)
Entity type:Individual
Prefix:DR
First Name:FREDRIC
Middle Name:L
Last Name:BONINE
Suffix:
Gender:M
Credentials:DDS, MS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29101121061223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1184980914OtherSOLE PROPRIETOR NPI
MI1184980914OtherSOLE PROPRIETOR NPI
MI382695532OtherTAX ID NUMBER