Provider Demographics
NPI:1235487851
Name:LOBERG, JOHN WILLIAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
Last Name:LOBERG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 E PINON FRONTAGE RD BLDG 200
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-5084
Mailing Address - Country:US
Mailing Address - Phone:505-599-9359
Mailing Address - Fax:505-599-8177
Practice Address - Street 1:2650 E PINON FRONTAGE RD BLDG 200
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-5084
Practice Address - Country:US
Practice Address - Phone:505-599-9359
Practice Address - Fax:505-599-8177
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00201838122300000X
NMDD4852122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist