Provider Demographics
NPI:1306859863
Name:MINCE-ENNIS, JOHN JAMES (DOM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JAMES
Last Name:MINCE-ENNIS
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4173
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-7173
Mailing Address - Country:US
Mailing Address - Phone:505-429-8859
Mailing Address - Fax:575-421-8852
Practice Address - Street 1:721 1/2 7TH ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4238
Practice Address - Country:US
Practice Address - Phone:505-429-8859
Practice Address - Fax:575-421-8852
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM809171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist