Provider Demographics
NPI:1811216146
Name:WIBICKI FAMILY DENTAL PC
Entity Type:Organization
Organization Name:WIBICKI FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WIBICKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-458-4758
Mailing Address - Street 1:4 CEDAR RIDGE DRIVE
Mailing Address - Street 2:4F
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156
Mailing Address - Country:US
Mailing Address - Phone:847-458-4758
Mailing Address - Fax:
Practice Address - Street 1:4 CEDAR RIDGE DRIVE
Practice Address - Street 2:4F
Practice Address - City:LAKE IN THE HILLS
Practice Address - State:IL
Practice Address - Zip Code:60156
Practice Address - Country:US
Practice Address - Phone:847-458-4758
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190218661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty