Provider Demographics
NPI:1407163900
Name:FORTUNA A. VARDEMAN, DDS, PC
Entity Type:Organization
Organization Name:FORTUNA A. VARDEMAN, DDS, PC
Other - Org Name:RANDOLPH FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FORTUNA
Authorized Official - Middle Name:ALAPAG
Authorized Official - Last Name:VARDEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:830-625-1400
Mailing Address - Street 1:651 S WALNUT AVE STE B
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-5764
Mailing Address - Country:US
Mailing Address - Phone:830-625-1400
Mailing Address - Fax:
Practice Address - Street 1:651 S WALNUT AVE STE B
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-5764
Practice Address - Country:US
Practice Address - Phone:830-625-1400
Practice Address - Fax:830-625-9031
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RANDOLPH FAMILY DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-03
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX188271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX091264401Medicaid