Healthcare Provider Details

I. General information

NPI: 1053883603
Provider Name (Legal Business Name): VS - LA PORTE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2018
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W FAIRMONT PKWY
LA PORTE TX
77571-6308
US

IV. Provider business mailing address

400 W FAIRMONT PKWY
LA PORTE TX
77571-6308
US

V. Phone/Fax

Practice location:
  • Phone: 832-460-5657
  • Fax: 346-998-1223
Mailing address:
  • Phone: 832-460-5657
  • Fax: 346-998-1223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN LE
Title or Position: OFFICE MANAGER
Credential:
Phone: 832-460-5657