MEDICARE: JON MARC VANSLATE D.D.S.,F.A.G.D.

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	1223G0001X	General Practice Dentistry	16023	TX

General Provider Information

NPI Number	:	1629120662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JON MARC VANSLATE D.D.S.,F.A.G.D.

Provider Business Mailing Address
First Line	:	1011 AUGUSTA DR
Second Line	:	SUITE 201
City	:	HOUSTON
State	:	TX
Zip	:	77057-2062
Country	:	US
Telephone Number	:	713-783-1993
Fax Number	:	713-266-3670

Provider Business Practice Location Address
First Line	:	1011 AUGUSTA DR
Second Line	:	SUITE 201
City	:	HOUSTON
State	:	TX
Zip	:	77057-2062
Country	:	US
Telephone Number	:	713-783-1993
Fax Number	:	713-266-3670

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	07/08/2007

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