Healthcare Provider Details

I. General information

NPI: 1831376284
Provider Name (Legal Business Name): RUSSELL T. WIBLE D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2008
Last Update Date: 01/22/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

689 N HERMITAGE RD
HERMITAGE PA
16148-3203
US

IV. Provider business mailing address

689 N HERMITAGE RD
HERMITAGE PA
16148-3203
US

V. Phone/Fax

Practice location:
  • Phone: 724-981-4222
  • Fax: 724-981-4228
Mailing address:
  • Phone: 724-981-4222
  • Fax: 724-981-4228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDS027889L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: