=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346971868
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANUPAMA BONAM DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2022
-----------------------------------------------------
Last Update Date | 06/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4315 FREDERICKSBURG RD
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78201-2017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-399-3958
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 803 SW MILITARY DR STE 132
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78221-1567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-923-2337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 38547
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------