Provider Demographics
NPI:1487803748
Name:KUBALL, KENT R (DENTIST)
Entity type:Individual
Prefix:DR
First Name:KENT
Middle Name:R
Last Name:KUBALL
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 HASSAN ST NE
Mailing Address - Street 2:PO BOX 49
Mailing Address - City:HUTCHINSON
Mailing Address - State:MN
Mailing Address - Zip Code:55350-1800
Mailing Address - Country:US
Mailing Address - Phone:320-587-2726
Mailing Address - Fax:320-587-2469
Practice Address - Street 1:10 HASSAN ST NE
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350-1800
Practice Address - Country:US
Practice Address - Phone:320-587-2726
Practice Address - Fax:320-587-2469
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10441122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN036871700Medicaid