=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093324675
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRISCO BRACES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2020
-----------------------------------------------------
Last Update Date | 07/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5285 DALLAS PKWY STE 500
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75034-9634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-543-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9822 POTRANCO RD STE 105
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78251-9608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-543-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAMES VANDEBERG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-902-9122
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------