Basic Information
| Provider Information | |||||||||
| NPI: | 1487055950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOBERG | ||||||||
| FirstName: | JARED | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13128 14TH STREET | ||||||||
| Address2: | |||||||||
| City: | CAMP PENDLETON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513437779 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2005 KNIGHT LANE BUILDING H | ||||||||
| Address2: | NAVY MEDICINE SUPPORT COMMAND ATTENTION MEDICAL STAFF | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 322120140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607253213 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2014 | ||||||||
| LastUpdateDate: | 09/15/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2901021195 | MI | Y | Dental Providers | Dentist |
No ID Information.