=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346726247
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL VIP, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2018
-----------------------------------------------------
Last Update Date | 10/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 404 W POWELL LN STE 102
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78753-6256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-715-1010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3262 WESTHEIMER RD # 833
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77098-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-715-1010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. LAURENCE E FENDRICH
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 561-715-1010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------