MEDICARE: NATIONAL ORTHODONTIX MANAGEMENT, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	13047	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	820296	OTHER	TX	UNITED CONCORDIA

General Provider Information

NPI Number	:	1306898481
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NATIONAL ORTHODONTIX MANAGEMENT, LLC

Provider Business Mailing Address
First Line	:	1620 S PADRE ISLAND DR
Second Line	:	SUITE 230B
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78416-1353
Country	:	US
Telephone Number	:	361-853-1900
Fax Number	:	361-853-1904

Provider Business Practice Location Address
First Line	:	1620 S PADRE ISLAND DR
Second Line	:	SUITE 230B
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78416-1353
Country	:	US
Telephone Number	:	361-853-1900
Fax Number	:	361-853-1904

Authorized Official
Title or Position	:	OPERATING MANAGER
Name	:	DR. JOHN G. VONDRAK
Credential	:	DDS
Telephone Number	:	361-853-1900

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	08/22/2020

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