Provider Demographics
NPI:1114702743
Name:KUBACKI, ERIC JEFFREY (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:JEFFREY
Last Name:KUBACKI
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 1:1214 OAKLEAF DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-1038
Mailing Address - Country:US
Mailing Address - Phone:815-531-2746
Mailing Address - Fax:
Practice Address - Street 1:2800 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4742
Practice Address - Country:US
Practice Address - Phone:618-474-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0337261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice