Provider Demographics
NPI:1750941118
Name:DOCTOR MOM PLLC
Entity type:Organization
Organization Name:DOCTOR MOM PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAUNTELLE
Authorized Official - Middle Name:DENE
Authorized Official - Last Name:BONMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-284-9498
Mailing Address - Street 1:1120 SHADETREE LN
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-5415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:844-296-5471
Practice Address - Street 1:1333 W MCDERMOTT DR STE 150
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-3088
Practice Address - Country:US
Practice Address - Phone:972-478-0696
Practice Address - Fax:844-296-5471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-18
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty