Healthcare Provider Details

I. General information

NPI: 1205990538
Provider Name (Legal Business Name): CHARLES M RUBASH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S MONROE
NEW LISBON WI
53950
US

IV. Provider business mailing address

600 S MONROE
NEW LISBON WI
53950
US

V. Phone/Fax

Practice location:
  • Phone: 608-562-5180
  • Fax:
Mailing address:
  • Phone: 608-562-5180
  • Fax: 608-562-3044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number02720
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: