Provider Demographics
NPI:1851696439
Name:KUBISIAK, PATRICIA (RDH)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:KUBISIAK
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 1:115 ELK AVE.
Mailing Address - Street 2:SUITE C
Mailing Address - City:CRESTED BUTTE
Mailing Address - State:CO
Mailing Address - Zip Code:81224-1442
Mailing Address - Country:US
Mailing Address - Phone:970-275-5000
Mailing Address - Fax:970-349-0903
Practice Address - Street 1:87 MERCHANT DR
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-3015
Practice Address - Country:US
Practice Address - Phone:970-252-8896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO903880124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COTRISHKUBYOtherCHP PLUS
COTRISHKUBYOtherCHP
COTRISHKUBYMedicaid
COTRISHKUBYMedicaid
COTRISHKUBYMedicare Oscar/Certification
COTRISHKUBYOtherCHP