Provider Demographics
NPI:1578308326
Name:AL RUBAYE, MUSTAFA
Entity type:Individual
Prefix:
First Name:MUSTAFA
Middle Name:
Last Name:AL RUBAYE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 UNIVERSITY AVE W APT 340
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-2025
Mailing Address - Country:US
Mailing Address - Phone:630-229-4354
Mailing Address - Fax:
Practice Address - Street 1:8241 S HOWELL AVE STE 100
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-8346
Practice Address - Country:US
Practice Address - Phone:414-762-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001633-15122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program