MEDICARE: VANDEBERG ORTHODONTICS, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	23213	TX

General Provider Information

NPI Number	:	1285816231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VANDEBERG ORTHODONTICS, P.A.

Provider Business Mailing Address
First Line	:	9822 POTRANCO RD STE 105
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78251-9608
Country	:	US
Telephone Number	:	210-543-8000
Fax Number	:	210-543-8002

Provider Business Practice Location Address
First Line	:	9822 POTRANCO RD STE 105
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78251-9608
Country	:	US
Telephone Number	:	210-543-8000
Fax Number	:	210-543-8002

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JAMES VANDEBERG
Credential	:	D.D.S. M.S.
Telephone Number	:	210-543-8000

Provider Enumeration Date	:	12/02/2007
Last Update Date	:	12/02/2007

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