Healthcare Provider Details

I. General information

NPI: 1265497564
Provider Name (Legal Business Name): MICHAEL S BUBON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 10/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N16W24132 PRAIRIE CT SUITE 150
WAUKESHA WI
53188-1178
US

IV. Provider business mailing address

N16W24132 PRAIRIE CT SUITE 150
WAUKESHA WI
53188-1178
US

V. Phone/Fax

Practice location:
  • Phone: 262-522-7447
  • Fax: 262-522-7448
Mailing address:
  • Phone: 262-522-7447
  • Fax: 262-522-7448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: