Provider Demographics
NPI:1053404897
Name:VARDEMAN, FORTUNA A (DENTIST)
Entity type:Individual
Prefix:DR
First Name:FORTUNA
Middle Name:A
Last Name:VARDEMAN
Suffix:
Gender:F
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 FM 3009 STE 104
Mailing Address - Street 2:
Mailing Address - City:SCHERTZ
Mailing Address - State:TX
Mailing Address - Zip Code:78154-1138
Mailing Address - Country:US
Mailing Address - Phone:210-658-9031
Mailing Address - Fax:210-658-8202
Practice Address - Street 1:3900 FM 3009 STE 104
Practice Address - Street 2:
Practice Address - City:SCHERTZ
Practice Address - State:TX
Practice Address - Zip Code:78154-1138
Practice Address - Country:US
Practice Address - Phone:210-658-9031
Practice Address - Fax:210-658-8202
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX188271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice