Provider Demographics
NPI:1083910988
Name:WALTER J KUCABA, DDS, MS, PA
Entity Type:Organization
Organization Name:WALTER J KUCABA, DDS, MS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:KUCABA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:864-585-0468
Mailing Address - Street 1:151 DILLON DR
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-1017
Mailing Address - Country:US
Mailing Address - Phone:864-585-0468
Mailing Address - Fax:864-585-0469
Practice Address - Street 1:151 DILLON DR
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1017
Practice Address - Country:US
Practice Address - Phone:864-585-0468
Practice Address - Fax:864-585-0469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-10
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6484860001Medicare NSC