MEDICARE: DR. KENNETH JAMES BOONE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	4531	LA

General Provider Information

NPI Number	:	1548257066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH JAMES BOONE DDS

Provider Business Mailing Address
First Line	:	1100 WILFORD HALL LOOP BLDG 4554
Second Line	:
City	:	JBSA LACKLAND
State	:	TX
Zip	:	78236-5638
Country	:	US
Telephone Number	:	210-565-0646
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 WILFORD HALL LOOP, BLDG 4554
Second Line	:	ATTN: 59 MDW/SGHC
City	:	SAN ANTONIO
State	:	TX
Zip	:	78236
Country	:	US
Telephone Number	:	210-292-6246
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	01/22/2021

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