Provider Demographics
NPI:1215669759
Name:RIEBE, BENJAMIN THOMAS (DDS)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:THOMAS
Last Name:RIEBE
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 1:3712 TOWER AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-5397
Mailing Address - Country:US
Mailing Address - Phone:715-392-5000
Mailing Address - Fax:
Practice Address - Street 1:3712 TOWER AVE STE A
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5397
Practice Address - Country:US
Practice Address - Phone:715-392-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001015-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice