Provider Demographics
NPI:1023110087
Name:GUBALA, MARY AGNES (RDH)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:AGNES
Last Name:GUBALA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12711 SE MILL PLAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-6053
Mailing Address - Country:US
Mailing Address - Phone:360-896-4484
Mailing Address - Fax:
Practice Address - Street 1:12711 SE MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6053
Practice Address - Country:US
Practice Address - Phone:360-896-4484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00002032124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist