Provider Demographics
NPI:1346971868
Name:BONAM, ANUPAMA (DDS)
Entity Type:Individual
Prefix:
First Name:ANUPAMA
Middle Name:
Last Name:BONAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 SW MILITARY DR STE 132
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78221-1567
Mailing Address - Country:US
Mailing Address - Phone:210-923-2337
Mailing Address - Fax:
Practice Address - Street 1:4315 FREDERICKSBURG RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78201-2017
Practice Address - Country:US
Practice Address - Phone:210-399-3958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38547122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty