Basic Information
| Provider Information | |||||||||
| NPI: | 1891425328 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONINE | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | FREDRIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3216 GOLF CLUB RD | ||||||||
| Address2: | |||||||||
| City: | HOWELL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488439001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178610742 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1515 E. HOSPITAL DRIVE | ||||||||
| Address2: | G1100 TOWSLEY CENTER | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342326048 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2022 | ||||||||
| LastUpdateDate: | 06/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2901601400 | MI | Y | Dental Providers | Dentist |
No ID Information.