Healthcare Provider Details

I. General information

NPI: 1811183841
Provider Name (Legal Business Name): KUBO ORTHODONTIC GROUP A DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2007
Last Update Date: 09/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6315 N FRESNO ST SUITE 101
FRESNO CA
93710-5273
US

IV. Provider business mailing address

6315 N FRESNO ST SUITE 101
FRESNO CA
93710-5273
US

V. Phone/Fax

Practice location:
  • Phone: 559-438-7600
  • Fax:
Mailing address:
  • Phone: 559-438-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD33611
License Number StateCA

VIII. Authorized Official

Name: DR. JAMES DOUGLAS KUBO
Title or Position: CFO
Credential: D.D.S.
Phone: 559-438-7600