Provider Demographics
NPI:1891710067
Name:WIBBELER, J STEPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:STEPHEN
Last Name:WIBBELER
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 1:15 1ST ST NE
Mailing Address - Street 2:BOX 990
Mailing Address - City:CHOTEAU
Mailing Address - State:MT
Mailing Address - Zip Code:59422-0990
Mailing Address - Country:US
Mailing Address - Phone:406-466-5662
Mailing Address - Fax:406-466-5662
Practice Address - Street 1:15 1ST ST NE
Practice Address - Street 2:
Practice Address - City:CHOTEAU
Practice Address - State:MT
Practice Address - Zip Code:59422-0990
Practice Address - Country:US
Practice Address - Phone:406-466-5662
Practice Address - Fax:406-466-5662
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT14361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT11-9353Medicaid