Provider Demographics
NPI:1841049202
Name:KUBILIUS, ELIZABETH GRACE (DMD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:GRACE
Last Name:KUBILIUS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:KRUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1404 CHRISTY AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-2041
Mailing Address - Country:US
Mailing Address - Phone:571-201-3983
Mailing Address - Fax:
Practice Address - Street 1:8310 PALOMAS AVE NE STE C
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5286
Practice Address - Country:US
Practice Address - Phone:505-588-5330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDB-2024-0146122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist