Healthcare Provider Details

I. General information

NPI: 1619973013
Provider Name (Legal Business Name): RONALD RICHARD KUBIAK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 02/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 BATAAN MEMORIAL E
LAS CRUCES NM
88011-6016
US

IV. Provider business mailing address

385 CALLE DE ALEGRA BLDG. A
LAS CRUCES NM
88005-3423
US

V. Phone/Fax

Practice location:
  • Phone: 505-382-2112
  • Fax: 505-382-5064
Mailing address:
  • Phone: 575-526-1105
  • Fax: 575-524-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD2015
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: