Healthcare Provider Details

I. General information

NPI: 1124083043
Provider Name (Legal Business Name): WALTER JOSEPH KUCABA DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 DILLON DR
SPARTANBURG SC
29307-1017
US

IV. Provider business mailing address

151 DILLON DR
SPARTANBURG SC
29307-1017
US

V. Phone/Fax

Practice location:
  • Phone: 864-585-0468
  • Fax: 864-585-0469
Mailing address:
  • Phone: 864-585-0468
  • Fax: 864-585-0469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number0218 PERIO
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: