Healthcare Provider Details

I. General information

NPI: 1700166162
Provider Name (Legal Business Name): WESLEY S. KUBO DDS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 08/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

458 MID CITIES BLVD
HURST TX
76054-2430
US

IV. Provider business mailing address

458 MID CITIES BLVD
HURST TX
76054-2430
US

V. Phone/Fax

Practice location:
  • Phone: 817-571-2100
  • Fax: 817-519-8269
Mailing address:
  • Phone: 817-571-2100
  • Fax: 817-519-8269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: WESLEY S KUBO
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 817-571-2100