Provider Demographics
NPI:1114646676
Name:BLUEBONNET PEDIATRIC DENTISTRY PLLC
Entity Type:Organization
Organization Name:BLUEBONNET PEDIATRIC DENTISTRY PLLC
Other - Org Name:BLUEBONNET PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:AMES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-472-0837
Mailing Address - Street 1:2650 BECKER DRIVE
Mailing Address - Street 2:
Mailing Address - City:BRENHAM
Mailing Address - State:TX
Mailing Address - Zip Code:77833
Mailing Address - Country:US
Mailing Address - Phone:979-451-6026
Mailing Address - Fax:979-246-0960
Practice Address - Street 1:2650 BECKER DRIVE
Practice Address - Street 2:
Practice Address - City:BRENHAM
Practice Address - State:TX
Practice Address - Zip Code:77833
Practice Address - Country:US
Practice Address - Phone:979-451-6026
Practice Address - Fax:979-246-0960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-26
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty