Provider Demographics
NPI:1285662817
Name:MOBLEY, JAMES MILTON (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MILTON
Last Name:MOBLEY
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 1:110 E. ROUTT AVENUE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004
Mailing Address - Country:US
Mailing Address - Phone:719-543-8711
Mailing Address - Fax:719-585-3038
Practice Address - Street 1:2030 LAKE AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3536
Practice Address - Country:US
Practice Address - Phone:719-564-4823
Practice Address - Fax:719-564-4858
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN-71191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO44526369Medicaid
0017550OtherDORAL
KS200372340AMedicaid