Healthcare Provider Details

I. General information

NPI: 1962823617
Provider Name (Legal Business Name): HOWARD J LUBIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/25/2013
Last Update Date: 12/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S TOWNLINE RD
WAUTOMA WI
54982-6922
US

IV. Provider business mailing address

400 S TOWNLINE RD
WAUTOMA WI
54982-6922
US

V. Phone/Fax

Practice location:
  • Phone: 920-787-5514
  • Fax: 920-787-4737
Mailing address:
  • Phone: 920-787-5514
  • Fax: 920-787-4737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number3187-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: