Provider Demographics
NPI:1841270030
Name:KUBALA, LOUIS REMBERT (DMD)
Entity type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:REMBERT
Last Name:KUBALA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3955 DRINKWATER STREET
Mailing Address - Street 2:
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310-1507
Mailing Address - Country:US
Mailing Address - Phone:904-349-2057
Mailing Address - Fax:
Practice Address - Street 1:US DENTAL ACTIVITY
Practice Address - Street 2:BLDG 171 4TH INNER LOOP RD
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310-1507
Practice Address - Country:US
Practice Address - Phone:760-380-3166
Practice Address - Fax:760-380-4996
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36961223G0001X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
BK8291762OtherFEDERAL DEA