Provider Demographics
NPI:1104367754
Name:SHURBA, KATHLEEN (RDH)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:SHURBA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4041 N CENTRAL AVE
Mailing Address - Street 2:BLDG.C
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-3330
Mailing Address - Country:US
Mailing Address - Phone:602-279-5262
Mailing Address - Fax:602-263-7870
Practice Address - Street 1:4041 N CENTRAL AVE
Practice Address - Street 2:BLDG.C
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-3330
Practice Address - Country:US
Practice Address - Phone:602-279-5262
Practice Address - Fax:602-263-7870
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6821124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist