Provider Demographics
NPI:1659596153
Name:BRIMACOMBE, COREY LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:LEE
Last Name:BRIMACOMBE
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 1:413 N 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4226
Mailing Address - Country:US
Mailing Address - Phone:715-842-4649
Mailing Address - Fax:715-842-7331
Practice Address - Street 1:413 N 17TH AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4226
Practice Address - Country:US
Practice Address - Phone:715-842-4649
Practice Address - Fax:715-842-7331
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50591223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5059OtherDELTA WI ID#
WI33756600Medicaid