Provider Demographics
NPI:1033550983
Name:BLUEBONNET ORAL SURGERY AND IMPLANTS PLLC
Entity Type:Organization
Organization Name:BLUEBONNET ORAL SURGERY AND IMPLANTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-344-9898
Mailing Address - Street 1:7300 BLANCO RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-4936
Mailing Address - Country:US
Mailing Address - Phone:210-344-9898
Mailing Address - Fax:210-344-9118
Practice Address - Street 1:7300 BLANCO RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-4936
Practice Address - Country:US
Practice Address - Phone:210-344-9898
Practice Address - Fax:210-344-9118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX123161223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX12316OtherDENTAL LICENSE NUMBER
TX14522OtherDENTAL LICENSE NUMBER