Provider Demographics
NPI:1932515020
Name:BOERNE ORTHODONTICS, PLLC
Entity Type:Organization
Organization Name:BOERNE ORTHODONTICS, PLLC
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
Authorized Official - Phone:830-331-8008
Mailing Address - Street 1:215 WEST BANDERA ROAD
Mailing Address - Street 2:SUITE # 112
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006
Mailing Address - Country:US
Mailing Address - Phone:210-902-9122
Mailing Address - Fax:
Practice Address - Street 1:215 W BANDERA RD
Practice Address - Street 2:SUITE # 112
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-2820
Practice Address - Country:US
Practice Address - Phone:830-331-8008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-09
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23213261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental