Provider Demographics
NPI:1285816231
Name:VANDEBERG ORTHODONTICS, P.A.
Entity Type:Organization
Organization Name:VANDEBERG ORTHODONTICS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:210-543-8000
Mailing Address - Street 1:9822 POTRANCO RD STE 105
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-9608
Mailing Address - Country:US
Mailing Address - Phone:210-543-8000
Mailing Address - Fax:210-543-8002
Practice Address - Street 1:9822 POTRANCO RD STE 105
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-9608
Practice Address - Country:US
Practice Address - Phone:210-543-8000
Practice Address - Fax:210-543-8002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-02
Last Update Date:2007-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23213261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental