Provider Demographics
NPI:1003890237
Name:HUBBARD, MICHAEL WAYNE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:HUBBARD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-2648
Mailing Address - Country:US
Mailing Address - Phone:270-783-3573
Mailing Address - Fax:270-783-4081
Practice Address - Street 1:1109 STATE ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2648
Practice Address - Country:US
Practice Address - Phone:270-783-3573
Practice Address - Fax:270-783-4081
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY59371223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60059375Medicaid
KY0679704Medicare ID - Type Unspecified
KY60059375Medicaid