MEDICARE: JOHN G. VONDRAK DDS

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	DD2276	NM

General Provider Information

NPI Number	:	1730151713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN G. VONDRAK DDS

Provider Business Mailing Address
First Line	:	920 N TELSHOR BLVD
Second Line	:	SUITE E
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-8244
Country	:	US
Telephone Number	:	505-521-0900
Fax Number	:	505-522-0154

Provider Business Practice Location Address
First Line	:	920 N TELSHOR BLVD
Second Line	:	SUITE E
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-8244
Country	:	US
Telephone Number	:	505-521-0900
Fax Number	:	505-522-0154

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	12/18/2007

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