MEDICARE: KUBO ORTHODONTIC GROUP A DENTAL CORPORATION

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	D33611	CA

General Provider Information

NPI Number	:	1811183841
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KUBO ORTHODONTIC GROUP A DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	6315 N FRESNO ST
Second Line	:	SUITE 101
City	:	FRESNO
State	:	CA
Zip	:	93710-5273
Country	:	US
Telephone Number	:	559-438-7600
Fax Number	:

Provider Business Practice Location Address
First Line	:	6315 N FRESNO ST
Second Line	:	SUITE 101
City	:	FRESNO
State	:	CA
Zip	:	93710-5273
Country	:	US
Telephone Number	:	559-438-7600
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	DR. JAMES DOUGLAS KUBO
Credential	:	D.D.S.
Telephone Number	:	559-438-7600

Provider Enumeration Date	:	09/24/2007
Last Update Date	:	09/24/2007

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