Provider Demographics
NPI:1710397559
Name:KRYSTAL, BONNIE K (DDS)
Entity type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:K
Last Name:KRYSTAL
Suffix:
Gender:F
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:PO BOX 1854
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91386-1854
Mailing Address - Country:US
Mailing Address - Phone:213-484-9063
Mailing Address - Fax:
Practice Address - Street 1:1803 W SUNSET BLVD # 1
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-3226
Practice Address - Country:US
Practice Address - Phone:213-484-9063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-02
Last Update Date:2014-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39670122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA39670OtherCALIF, DENTAL LIC.