Provider Demographics
NPI:1235104753
Name:WILSON, JOLANTA KUBICA (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOLANTA
Middle Name:KUBICA
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1363
Mailing Address - Country:US
Mailing Address - Phone:616-866-0164
Mailing Address - Fax:
Practice Address - Street 1:610 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1363
Practice Address - Country:US
Practice Address - Phone:616-866-0164
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI188951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice