Provider Demographics
NPI:1710216197
Name:DUBOSE, KATHLEEN SUZETTE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:SUZETTE
Last Name:DUBOSE
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 1:6 TRIANGLE PARK DR
Mailing Address - Street 2:SUITE 603
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-3403
Mailing Address - Country:US
Mailing Address - Phone:513-851-0044
Mailing Address - Fax:513-851-9130
Practice Address - Street 1:6 TRIANGLE PARK DR
Practice Address - Street 2:SUITE 603
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-3403
Practice Address - Country:US
Practice Address - Phone:513-851-0044
Practice Address - Fax:513-851-9130
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH19505122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0229952Medicaid