Provider Demographics
NPI:1619568748
Name:MOBLEY, SHANPELLA M (DA)
Entity Type:Individual
Prefix:
First Name:SHANPELLA
Middle Name:M
Last Name:MOBLEY
Suffix:
Gender:F
Credentials:DA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1538 BUTLER ST SE APT 103
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-4378
Mailing Address - Country:US
Mailing Address - Phone:301-541-9496
Mailing Address - Fax:
Practice Address - Street 1:427 9TH ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1528
Practice Address - Country:US
Practice Address - Phone:210-951-3280
Practice Address - Fax:210-858-9220
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDENA00822126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCDENA000822Medicaid