Basic Information
| Provider Information | |||||||||
| NPI: | 1831734045 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KO | ||||||||
| FirstName: | BONA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 E ALGONQUIN RD STE 610 | ||||||||
| Address2: | |||||||||
| City: | SCHAUMBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601734166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889884066 | ||||||||
| FaxNumber: | 8474964850 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 NE 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791075214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889884066 | ||||||||
| FaxNumber: | 8474964850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2019 | ||||||||
| LastUpdateDate: | 11/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 35788 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.