MEDICARE: DR. RICHARD M. LUBOW D.M.D., M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	10141315-9921	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10141315-8903	OTHER	UT	PAHARMACY
2	10141315-9921	OTHER	UT	DENTISTRY

General Provider Information

NPI Number	:	1710965959
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD M. LUBOW D.M.D., M.S.

Provider Business Mailing Address
First Line	:	929 W SUNSET BLVD
Second Line	:
City	:	SAINT GEORGE
State	:	UT
Zip	:	84770-4865
Country	:	US
Telephone Number	:	515-705-8358
Fax Number	:

Provider Business Practice Location Address
First Line	:	929 W SUNSET BLVD
Second Line	:
City	:	SAINT GEORGE
State	:	UT
Zip	:	84770
Country	:	US
Telephone Number	:	515-705-8358
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2006
Last Update Date	:	06/07/2018

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