MEDICARE: DR. JAMES ROBERT VANDEBERG D.D.S, M.S.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	23213	TX

General Provider Information

NPI Number	:	1750562021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES ROBERT VANDEBERG D.D.S, M.S.

Provider Business Mailing Address
First Line	:	9822 POTRANCO RD
Second Line	:	SUITE 105
City	:	SAN ANTONIO
State	:	TX
Zip	:	78251-9607
Country	:	US
Telephone Number	:	210-543-8000
Fax Number	:	210-543-8002

Provider Business Practice Location Address
First Line	:	9822 POTRANCO RD
Second Line	:	SUITE 105
City	:	SAN ANTONIO
State	:	TX
Zip	:	78251-9607
Country	:	US
Telephone Number	:	210-543-8000
Fax Number	:	210-543-8002

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

Provider Enumeration Date	:	11/15/2007
Last Update Date	:	12/02/2007

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