Provider Demographics
NPI:1659574051
Name:WIBBY, WAYNE WILSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:WILSON
Last Name:WIBBY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 BELLEVUE AVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5618
Mailing Address - Country:US
Mailing Address - Phone:207-942-4155
Mailing Address - Fax:207-942-1819
Practice Address - Street 1:20 BELLEVUE AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5618
Practice Address - Country:US
Practice Address - Phone:207-942-4155
Practice Address - Fax:207-942-1819
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME21451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice