MEDICARE: DR. LOUIS REMBERT KUBALA DMD

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	1223G0001X	General Practice Dentistry	3696	SC
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	3696	SC

General Provider Information

NPI Number	:	1841270030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LOUIS REMBERT KUBALA DMD

Provider Business Mailing Address
First Line	:	3955 DRINKWATER STREET
Second Line	:
City	:	FORT IRWIN
State	:	CA
Zip	:	92310-1507
Country	:	US
Telephone Number	:	904-349-2057
Fax Number	:

Provider Business Practice Location Address
First Line	:	US DENTAL ACTIVITY
Second Line	:	BLDG 171 4TH INNER LOOP RD
City	:	FORT IRWIN
State	:	CA
Zip	:	92310-1507
Country	:	US
Telephone Number	:	760-380-3166
Fax Number	:	760-380-4996

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

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	03/07/2023

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