Provider Demographics
NPI:1053835181
Name:LE, BONNIE (DMD)
Entity type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:
Last Name:LE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 103 BOX 4502
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09603-0046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31ST MEDICAL GROUP
Practice Address - Street 2:UNIT 6180
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09604-6180
Practice Address - Country:US
Practice Address - Phone:043-430-5105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101716122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist