Provider Demographics
NPI:1659689776
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: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:210-658-9031
Mailing Address - Street 1:117 E LANGLEY
Mailing Address - Street 2:
Mailing Address - City:UNIVERSAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78148-4414
Mailing Address - Country:US
Mailing Address - Phone:210-658-9031
Mailing Address - Fax:210-658-8202
Practice Address - Street 1:117 E LANGLEY
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78148-4414
Practice Address - Country:US
Practice Address - Phone:210-658-9031
Practice Address - Fax:210-658-8202
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RANDOLPH FAMILY DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX188271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty