Provider Demographics
NPI:1376794537
Name:NATIONAL ORTHODONTIX MGMT LLC
Entity Type:Organization
Organization Name:NATIONAL ORTHODONTIX MGMT LLC
Other - Org Name:ORTHODONTIX LTD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
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:361-853-1900
Mailing Address - Street 1:5711 MCPHERSON RD
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-6837
Mailing Address - Country:US
Mailing Address - Phone:361-853-1900
Mailing Address - Fax:361-853-1904
Practice Address - Street 1:5711 MCPHERSON RD
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-6837
Practice Address - Country:US
Practice Address - Phone:361-853-1900
Practice Address - Fax:361-853-1904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX130471223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX009297504Medicaid
TX730151713Medicaid
TX009297503Medicaid