Provider Demographics
NPI:1386811677
Name:MATTHEW KUBOVICH
Entity type:Organization
Organization Name:MATTHEW KUBOVICH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:PERRY
Authorized Official - Last Name:KUBOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:515-225-0066
Mailing Address - Street 1:4949 WESTOWN PKWY
Mailing Address - Street 2:STE 150
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-6702
Mailing Address - Country:US
Mailing Address - Phone:515-225-0066
Mailing Address - Fax:515-226-0998
Practice Address - Street 1:4949 WESTOWN PKWY
Practice Address - Street 2:SUITE 150
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-6702
Practice Address - Country:US
Practice Address - Phone:515-225-0066
Practice Address - Fax:515-226-0998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1291575Medicaid
IA1745344OtherUNITED CONCORDIA
IA35184OtherBLUE CROSS BLUE SHIELD