Provider Demographics
NPI:1861509572
Name:KUBOTA, MICHIO (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHIO
Middle Name:
Last Name:KUBOTA
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 1:694 S COOPER RD STE A2
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-7165
Mailing Address - Country:US
Mailing Address - Phone:480-632-2255
Mailing Address - Fax:480-632-7846
Practice Address - Street 1:694 S COOPER RD STE A2
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-7165
Practice Address - Country:US
Practice Address - Phone:480-632-2255
Practice Address - Fax:480-632-7846
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ44171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice