Provider Demographics
NPI:1164880787
Name:BUONICONTI, KELLY A (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:A
Last Name:BUONICONTI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4416 N MOODY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3007
Mailing Address - Country:US
Mailing Address - Phone:773-580-9827
Mailing Address - Fax:
Practice Address - Street 1:26112 OVERLOOK PKWY
Practice Address - Street 2:STE 1108
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78260-6051
Practice Address - Country:US
Practice Address - Phone:210-293-0810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRES.3571390200000X
TX31847122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program