Healthcare Provider Details

I. General information

NPI: 1538783485
Provider Name (Legal Business Name): ANDREW WADE RUBLE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2020
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2575
US

IV. Provider business mailing address

605 STAGECOACH DR
JACKSONVILLE NC
28546-8665
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-4357
  • Fax:
Mailing address:
  • Phone: 304-820-2855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDGD.9630.GD
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: