Provider Demographics
NPI:1720336696
Name:GARY R HUBBARD DDS PC
Entity Type:Organization
Organization Name:GARY R HUBBARD DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:HUBBARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:517-332-2422
Mailing Address - Street 1:3515 COOLIDGE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-8014
Mailing Address - Country:US
Mailing Address - Phone:517-332-2422
Mailing Address - Fax:517-332-0810
Practice Address - Street 1:3515 COOLIDGE RD
Practice Address - Street 2:SUITE C
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8014
Practice Address - Country:US
Practice Address - Phone:517-332-2422
Practice Address - Fax:517-332-0810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-26
Last Update Date:2012-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI11821332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6712190001Medicare NSC