Provider Demographics
NPI:1093767212
Name:NATIONAL ORTHODONTIX MANAGEMENT, PLLC
Entity Type:Organization
Organization Name:NATIONAL ORTHODONTIX MANAGEMENT, PLLC
Other - Org Name:SUN ORTHODONTIX OF LAS CRUCES PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATING MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:VONDRAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-521-0900
Mailing Address - Street 1:920 N TELSHOR BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8244
Mailing Address - Country:US
Mailing Address - Phone:575-521-0900
Mailing Address - Fax:575-521-0128
Practice Address - Street 1:920 N TELSHOR BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8244
Practice Address - Country:US
Practice Address - Phone:575-521-0900
Practice Address - Fax:575-521-0128
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NATIONAL ORTHODONTIX MANAGEMENT, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-16
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD22761223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM105971Medicaid
NM00785351Medicaid