Healthcare Provider Details

I. General information

NPI: 1588707921
Provider Name (Legal Business Name): JAMES A. KOUBA, D.D.S., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 S PINE ST
BLOOMFIELD IA
52537-1519
US

IV. Provider business mailing address

107 S PINE ST
BLOOMFIELD IA
52537-1519
US

V. Phone/Fax

Practice location:
  • Phone: 641-664-1121
  • Fax: 641-664-2107
Mailing address:
  • Phone: 641-664-1121
  • Fax: 641-664-2107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number06138
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0128389
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: DR. JAMES A KOUBA
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 641-664-1121