Provider Demographics
NPI:1033988530
Name:WIBBEN, BROOK (RDH)
Entity Type:Individual
Prefix:
First Name:BROOK
Middle Name:
Last Name:WIBBEN
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 1:413 N 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4611
Mailing Address - Country:US
Mailing Address - Phone:715-298-3983
Mailing Address - Fax:
Practice Address - Street 1:103 W MCMILLAN ST STE 2
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-1039
Practice Address - Country:US
Practice Address - Phone:715-298-3983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI100335416124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist