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General NPI Number Information
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NPI Number | 1164880787
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Entity Type | Individual
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Provider Name | KELLY A BUONICONTI D.M.D.
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Gender | Female
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Dates
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Enumeration Date | 02/10/2016
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Last Update Date | 06/07/2016
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Provider Practice Location Address
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Address Line | 26112 OVERLOOK PKWY STE 1108
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City | SAN ANTONIO
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State | TX
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Zip | 78260-6051
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Country | US
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Telephone | 210-293-0810
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Fax |
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Provider Business Mailing Address
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Address Line | 4416 N MOODY AVE
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City | CHICAGO
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State | IL
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Zip | 60630-3007
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Country | US
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Telephone | 773-580-9827
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | RES.3571
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 31847
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License Number State | TX
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