Provider Demographics
NPI:1336132984
Name:DIBELKA, JAMES JOSEPH JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:JOSEPH
Last Name:DIBELKA
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-0160
Mailing Address - Country:US
Mailing Address - Phone:505-368-6001
Mailing Address - Fax:
Practice Address - Street 1:US HWY 491 NORTH
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420
Practice Address - Country:US
Practice Address - Phone:505-368-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401 0062001223G0001X
CA346911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0401 006200OtherDENTAL LICENSE