Provider Demographics
NPI:1285760900
Name:GRIGOR, BONNY GAYLE (DMD)
Entity type:Individual
Prefix:DR
First Name:BONNY
Middle Name:GAYLE
Last Name:GRIGOR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:BONNY
Other - Middle Name:GRIGOR
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:6015 LOHMANS FORD RD
Mailing Address - Street 2:SUITE103
Mailing Address - City:LAGO VISTA
Mailing Address - State:TX
Mailing Address - Zip Code:78645-5105
Mailing Address - Country:US
Mailing Address - Phone:512-267-5200
Mailing Address - Fax:
Practice Address - Street 1:6015 LOHMANS FORD RD
Practice Address - Street 2:SUITE103
Practice Address - City:LAGO VISTA
Practice Address - State:TX
Practice Address - Zip Code:78645-5105
Practice Address - Country:US
Practice Address - Phone:512-267-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25278122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist