Basic Information
| Provider Information | |||||||||
| NPI: | 1154987915 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AL KUBAISI | ||||||||
| FirstName: | GHAZWAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 964 LYNN RD SW | ||||||||
| Address2: | |||||||||
| City: | HUTCHINSON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553503151 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1960 25TH AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329603015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619999650 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2019 | ||||||||
| LastUpdateDate: | 08/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D14196 | MN | N | Dental Providers | Dentist | 122300000X | DN26294 | FL | Y | Dental Providers | Dentist |
No ID Information.