Basic Information
| Provider Information | |||||||||
| NPI: | 1598948168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUBBEN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 905 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507034407 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 905 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507034407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192724300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2007 | ||||||||
| LastUpdateDate: | 12/06/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 01839 | IA | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 0076372 | 05 | IA | MEDICAID |