Healthcare Provider Details

I. General information

NPI: 1164449088
Provider Name (Legal Business Name): BARTON A. KUBELKA, D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10951 CHESTNUT ST
LOS ALAMITOS CA
90720-2378
US

IV. Provider business mailing address

10951 CHESTNUT ST
LOS ALAMITOS CA
90720-2378
US

V. Phone/Fax

Practice location:
  • Phone: 562-594-8769
  • Fax: 562-594-5631
Mailing address:
  • Phone: 562-594-8769
  • Fax: 562-594-5631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22632
License Number StateCA

VIII. Authorized Official

Name: BARTON A KUBELKA
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 562-594-8769