Healthcare Provider Details

I. General information

NPI: 1174747687
Provider Name (Legal Business Name): RICHARD ALAN WILBUR DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 11/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 KALE CT
SAINT ROBERT MO
65584-3816
US

IV. Provider business mailing address

111 KALE CT
SAINT ROBERT MO
65584-3816
US

V. Phone/Fax

Practice location:
  • Phone: 262-930-0163
  • Fax:
Mailing address:
  • Phone: 262-930-0163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5001682-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: