Healthcare Provider Details

I. General information

NPI: 1114646676
Provider Name (Legal Business Name): BLUEBONNET PEDIATRIC DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 08/08/2023
Certification Date: 08/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 BECKER DRIVE
BRENHAM TX
77833
US

IV. Provider business mailing address

2650 BECKER DRIVE
BRENHAM TX
77833
US

V. Phone/Fax

Practice location:
  • Phone: 979-451-6026
  • Fax: 979-246-0960
Mailing address:
  • Phone: 979-451-6026
  • Fax: 979-246-0960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JONATHAN CHARLES AMES
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 801-472-0837