Healthcare Provider Details

I. General information

NPI: 1982851531
Provider Name (Legal Business Name): JASON SCOTT SOBKOWSKI D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E NIZHONI BLVD
GALLUP NM
87301-5748
US

IV. Provider business mailing address

3706 CHACO DR
GALLUP NM
87301-4555
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax:
Mailing address:
  • Phone: 618-977-1140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019026207
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2007026095
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: