=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740733138
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN PAUL KUEBLER D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2016
-----------------------------------------------------
Last Update Date | 08/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40W320 LA FOX RD. SUITE D
-----------------------------------------------------
City | ST CHARLES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-388-9999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40W320 LA FOX RD. SUITE D
-----------------------------------------------------
City | ST CHARLES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-388-9999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019030717
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------