Provider Demographics
NPI:1225213176
Name:VANDE MATRAM PERIODONTOLOGY, PA
Entity Type:Organization
Organization Name:VANDE MATRAM PERIODONTOLOGY, PA
Other - Org Name:RANDHIR K KAPOOR, DDS., PHD.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDHIR
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:KAPOOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PHD
Authorized Official - Phone:817-741-4867
Mailing Address - Street 1:1674 KELLER PKWY
Mailing Address - Street 2:# 160
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-3751
Mailing Address - Country:US
Mailing Address - Phone:817-741-4867
Mailing Address - Fax:817-741-3333
Practice Address - Street 1:1674 KELLER PKWY
Practice Address - Street 2:# 160
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3751
Practice Address - Country:US
Practice Address - Phone:817-741-4867
Practice Address - Fax:817-741-3333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX191551223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty