Healthcare Provider Details

I. General information

NPI: 1285816231
Provider Name (Legal Business Name): VANDEBERG ORTHODONTICS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2007
Last Update Date: 12/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9822 POTRANCO RD STE 105
SAN ANTONIO TX
78251-9608
US

IV. Provider business mailing address

9822 POTRANCO RD STE 105
SAN ANTONIO TX
78251-9608
US

V. Phone/Fax

Practice location:
  • Phone: 210-543-8000
  • Fax: 210-543-8002
Mailing address:
  • Phone: 210-543-8000
  • Fax: 210-543-8002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number23213
License Number StateTX

VIII. Authorized Official

Name: DR. JAMES VANDEBERG
Title or Position: OWNER
Credential: D.D.S. M.S.
Phone: 210-543-8000