MEDICARE: DR. KELLY A BUONICONTI D.M.D.

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	390200000X	Student in an Organized Health Care Education/Training Program	RES.3571	OH
2	122300000X	Dentist	31847	TX

General Provider Information

NPI Number	:	1164880787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY A BUONICONTI D.M.D.

Provider Business Mailing Address
First Line	:	4416 N MOODY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-3007
Country	:	US
Telephone Number	:	773-580-9827
Fax Number	:

Provider Business Practice Location Address
First Line	:	26112 OVERLOOK PKWY
Second Line	:	STE 1108
City	:	SAN ANTONIO
State	:	TX
Zip	:	78260-6051
Country	:	US
Telephone Number	:	210-293-0810
Fax Number	:

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

Provider Enumeration Date	:	02/10/2016
Last Update Date	:	06/07/2016

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