Healthcare Provider Details

I. General information

NPI: 1841270030
Provider Name (Legal Business Name): LOUIS REMBERT KUBALA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US DENTAL ACTIVITY BLDG 171 4TH INNER LOOP RD
FORT IRWIN CA
92310-1507
US

IV. Provider business mailing address

3955 DRINKWATER STREET
FORT IRWIN CA
92310-1507
US

V. Phone/Fax

Practice location:
  • Phone: 760-380-3166
  • Fax: 760-380-4996
Mailing address:
  • Phone: 904-349-2057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3696
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3696
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: