Provider Demographics
NPI:1811947740
Name:KUBOTA, GLENN T III (DDS)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:T
Last Name:KUBOTA
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 21ST ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95818-2539
Mailing Address - Country:US
Mailing Address - Phone:916-452-3394
Mailing Address - Fax:916-452-6469
Practice Address - Street 1:2650 21ST ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95818-2539
Practice Address - Country:US
Practice Address - Phone:916-452-3394
Practice Address - Fax:916-452-6469
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0341371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice