Healthcare Provider Details

I. General information

NPI: 1093767212
Provider Name (Legal Business Name): NATIONAL ORTHODONTIX MANAGEMENT, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 N TELSHOR BLVD SUITE E
LAS CRUCES NM
88011-8244
US

IV. Provider business mailing address

920 N TELSHOR BLVD SUITE E
LAS CRUCES NM
88011-8244
US

V. Phone/Fax

Practice location:
  • Phone: 575-521-0900
  • Fax: 575-521-0128
Mailing address:
  • Phone: 575-521-0900
  • Fax: 575-521-0128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD2276
License Number StateNM

VIII. Authorized Official

Name: DR. JOHN G. VONDRAK
Title or Position: OPERATING MANAGER
Credential: DDS
Phone: 505-521-0900