Provider Demographics
NPI:1942381801
Name:HUBBARD, DELORES (DDS)
Entity Type:Individual
Prefix:DR
First Name:DELORES
Middle Name:
Last Name:HUBBARD
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 1:1784 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30344-4148
Mailing Address - Country:US
Mailing Address - Phone:404-766-8559
Mailing Address - Fax:404-766-7742
Practice Address - Street 1:1784 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30344-4148
Practice Address - Country:US
Practice Address - Phone:404-766-8559
Practice Address - Fax:404-766-7742
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0094371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00220712CMedicaid