Healthcare Provider Details

I. General information

NPI: 1730151713
Provider Name (Legal Business Name): JOHN G. VONDRAK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 12/18/2007
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: 505-521-0900
  • Fax: 505-522-0154
Mailing address:
  • Phone: 505-521-0900
  • Fax: 505-522-0154

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:
Title or Position:
Credential:
Phone: