Provider Demographics
NPI:1376110247
Name:WILLFAHRT, REBECCA ANN
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:WILLFAHRT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W MCMILLAN ST
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-6013
Mailing Address - Country:US
Mailing Address - Phone:715-387-1702
Mailing Address - Fax:
Practice Address - Street 1:306 W MCMILLAN ST
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-6013
Practice Address - Country:US
Practice Address - Phone:715-387-1702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI100266-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist