Provider Demographics
NPI:1275004343
Name:UBAU, JORGE WILDER (DH)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:WILDER
Last Name:UBAU
Suffix:
Gender:M
Credentials:DH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11645 BISCAYNE BLVD STE 207
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33181-3138
Mailing Address - Country:US
Mailing Address - Phone:305-538-8835
Mailing Address - Fax:305-938-4044
Practice Address - Street 1:710 ALTON RD
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-5504
Practice Address - Country:US
Practice Address - Phone:305-538-8835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH15723124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113633000Medicaid