Provider Demographics
NPI:1922208867
Name:KUCERA, REBECCA JOHNSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:JOHNSON
Last Name:KUCERA
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 1:1489 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-1187
Mailing Address - Country:US
Mailing Address - Phone:304-645-0251
Mailing Address - Fax:304-645-0252
Practice Address - Street 1:1489 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-1187
Practice Address - Country:US
Practice Address - Phone:304-645-0251
Practice Address - Fax:304-645-0252
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV37831223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
800340665OtherTAX ID
WV3810006780Medicaid
WV3783OtherSTATE OF WV DENTAL LICENS