Healthcare Provider Details

I. General information

NPI: 1942930821
Provider Name (Legal Business Name): NICHOLAS MICHAEL DUBINA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 S MAIN ST
DUPO IL
62239-1347
US

IV. Provider business mailing address

195 S MAIN ST
DUPO IL
62239-1347
US

V. Phone/Fax

Practice location:
  • Phone: 618-286-4400
  • Fax:
Mailing address:
  • Phone: 618-286-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2022021029
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019033768
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: