Healthcare Provider Details

I. General information

NPI: 1700987302
Provider Name (Legal Business Name): JAN BUBLIK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 INDEPENDENCE LN
WAUSAU WI
54403-5197
US

IV. Provider business mailing address

210 INDEPENDENCE LN
WAUSAU WI
54403-5197
US

V. Phone/Fax

Practice location:
  • Phone: 715-203-1305
  • Fax: 866-906-0578
Mailing address:
  • Phone: 715-203-1305
  • Fax: 866-906-0578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number050499-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: