Provider Demographics
NPI:1528167236
Name:KOUBSLEY, ROBERT WARREN (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WARREN
Last Name:KOUBSLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 1ST ST N
Mailing Address - Street 2:#102
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-255-9048
Mailing Address - Fax:320-251-4745
Practice Address - Street 1:3400 1ST ST N
Practice Address - Street 2:#102
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-255-9048
Practice Address - Fax:320-251-4745
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN 87781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4347273OtherMN STATE TAX ID