Healthcare Provider Details

I. General information

NPI: 1568670123
Provider Name (Legal Business Name): KEVIN ROSS RUBNICH D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 WASHINGTON ST
GLOUCESTER MA
01930-4836
US

IV. Provider business mailing address

606 POND ST
SOUTH WEYMOUTH MA
02190-1278
US

V. Phone/Fax

Practice location:
  • Phone: 978-282-8899
  • Fax:
Mailing address:
  • Phone: 781-812-0838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number18425
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: