Provider Demographics
NPI:1881811677
Name:HUBERT, KATHLEEN O (DDS)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:O
Last Name:HUBERT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12233 CHAMPLIN DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-1930
Mailing Address - Country:US
Mailing Address - Phone:763-323-0678
Mailing Address - Fax:763-323-9102
Practice Address - Street 1:12233 CHAMPLIN DR
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-1930
Practice Address - Country:US
Practice Address - Phone:763-323-0678
Practice Address - Fax:763-323-9102
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND9624122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist