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General NPI Number Information
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NPI Number | 1851777304
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Entity Type | Individual
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Provider Name | JAMES KELLAN VILLALON DDS, MPH
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Gender | Male
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Dates
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Enumeration Date | 08/07/2015
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Last Update Date | 12/10/2020
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Provider Practice Location Address
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Address Line | 1225 N MAIN ST STE 207
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City | PUEBLO
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State | CO
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Zip | 81003-2857
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Country | US
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Telephone | 719-286-0733
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Fax |
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Provider Business Mailing Address
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Address Line | 1225 N MAIN ST STE 207
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City | PUEBLO
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State | CO
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Zip | 81003-2857
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Country | US
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Telephone | 719-286-0733
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 11742
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 203024
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License Number State | CO
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Taxonomy #3
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Taxonomy Code | 1223D0004X
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Taxonomy Name | Dental Anesthesiology
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License Number | GEN.02786194
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License Number State | CO
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