Provider Demographics
NPI:1619315983
Name:THIBAUDEAU, REBECCA ANNE (DDS)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANNE
Last Name:THIBAUDEAU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ANNE
Other - Last Name:LEHMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:110 N BUTTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-1718
Mailing Address - Country:US
Mailing Address - Phone:847-372-4139
Mailing Address - Fax:
Practice Address - Street 1:110 N BUTTERFIELD RD
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-1718
Practice Address - Country:US
Practice Address - Phone:847-247-6453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-10
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.029384122300000X
WI7065-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist