Provider Demographics
NPI:1508363698
Name:JRV ORTHODONTICS, PLLC
Entity Type:Organization
Organization Name:JRV ORTHODONTICS, PLLC
Other - Org Name:SAN ANTONIO ORTHODONTICS
Other - Org Type:Doing Business As
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:210-902-9122
Mailing Address - Street 1:8536 ALYDAR CIR
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78015-4434
Mailing Address - Country:US
Mailing Address - Phone:210-902-9122
Mailing Address - Fax:
Practice Address - Street 1:12315 JUDSON RD STE 218
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3264
Practice Address - Country:US
Practice Address - Phone:210-656-3531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23213261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental