Provider Demographics
NPI:1104198837
Name:ROBERT W. KOUBSKY, D.D.S.
Entity Type:Organization
Organization Name:ROBERT W. KOUBSKY, D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:KOUBSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-255-9048
Mailing Address - Street 1:3400 1ST ST N
Mailing Address - Street 2:SUITE #102
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4000
Mailing Address - Country:US
Mailing Address - Phone:320-255-9048
Mailing Address - Fax:320-251-4745
Practice Address - Street 1:3400 1ST ST N
Practice Address - Street 2:SUITE #102
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4000
Practice Address - Country:US
Practice Address - Phone:320-255-9048
Practice Address - Fax:320-251-4745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN87781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty