Healthcare Provider Details

I. General information

NPI: 1285269480
Provider Name (Legal Business Name): MARK ZIGGY VRANA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2020
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2830 BILL OWENS PKWY
LONGVIEW TX
75605-2102
US

IV. Provider business mailing address

2830 BILL OWENS PKWY
LONGVIEW TX
75605-2102
US

V. Phone/Fax

Practice location:
  • Phone: 903-759-0282
  • Fax:
Mailing address:
  • Phone: 903-759-0282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number39277
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: