Provider Demographics
NPI:1902938863
Name:BONDURANT, JERRY LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEE
Last Name:BONDURANT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:SO CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-1823
Mailing Address - Country:US
Mailing Address - Phone:304-744-6962
Mailing Address - Fax:
Practice Address - Street 1:1900 SCHOOL ST
Practice Address - Street 2:KANAWHA DENTAL HEALTH COUNCIL INC
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25312-1524
Practice Address - Country:US
Practice Address - Phone:304-348-6613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1980122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0012835000Medicaid
WV0133364000Medicaid