Provider Demographics
NPI:1831376284
Name:WIBLE, RUSSELL T (DMD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:T
Last Name:WIBLE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:689 N HERMITAGE RD
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-3203
Mailing Address - Country:US
Mailing Address - Phone:724-981-4222
Mailing Address - Fax:724-981-4228
Practice Address - Street 1:689 N HERMITAGE RD
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-3203
Practice Address - Country:US
Practice Address - Phone:724-981-4222
Practice Address - Fax:724-981-4228
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-29
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS027889L204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000325486OtherANTHEM
PA204563OtherUPMC
PAHMO2375673OtherAETNA
PA419683OtherBC/BS
PAPPO4420848OtherAETNA
PAHMO2375673OtherAETNA