Provider Demographics
NPI:1194776906
Name:UBBEN DERMATOLOGY CLINIC
Entity type:Organization
Organization Name:UBBEN DERMATOLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:UBBEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-855-1247
Mailing Address - Street 1:5 CUNNINGHAM COR
Mailing Address - Street 2:
Mailing Address - City:BELLA VISTA
Mailing Address - State:AR
Mailing Address - Zip Code:72714-3520
Mailing Address - Country:US
Mailing Address - Phone:479-855-1247
Mailing Address - Fax:479-855-1249
Practice Address - Street 1:5 CUNNINGHAM COR
Practice Address - Street 2:
Practice Address - City:BELLA VISTA
Practice Address - State:AR
Practice Address - Zip Code:72714-3520
Practice Address - Country:US
Practice Address - Phone:479-855-1247
Practice Address - Fax:479-855-1249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-8212174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR122172001Medicaid
ARA94211Medicare UPIN
AR122172001Medicaid