1053404897 NPI number — DR. FORTUNA A VARDEMAN DENTIST

Table of content: DR. FORTUNA A VARDEMAN DENTIST (NPI 1053404897)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053404897 NPI number — DR. FORTUNA A VARDEMAN DENTIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VARDEMAN
Provider First Name:
FORTUNA
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DENTIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053404897
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3900 FM 3009 STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCHERTZ
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78154-1138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-658-9031
Provider Business Mailing Address Fax Number:
210-658-8202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3900 FM 3009 STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCHERTZ
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78154-1138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-658-9031
Provider Business Practice Location Address Fax Number:
210-658-8202
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  18827 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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