Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 11742 | CT |
N | 122300000X | Dentist | 203024 | CO |
Y | 1223D0004X | Dentist Anesthesiologist | GEN.02786194 | CO |
NPI | 1851777304 |
---|---|
Provider Name | Dr. James Kellan Villalon |
First Address | Pueblo, CO 81003-2857 |
Second Address | Pueblo, CO 81003-2857 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/08/2015 |
Last Update Date | 10/12/2020 |