Provider Demographics
NPI:1427050483
Name:WIBERG, RICHARD A (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:WIBERG
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 1:1790 LEXINGTON AVE N
Mailing Address - Street 2:STE B
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-6167
Mailing Address - Country:US
Mailing Address - Phone:651-488-5557
Mailing Address - Fax:651-488-0014
Practice Address - Street 1:1790 LEXINGTON AVE N
Practice Address - Street 2:STE B
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-6167
Practice Address - Country:US
Practice Address - Phone:651-488-5557
Practice Address - Fax:651-488-0014
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-02
Last Update Date:2007-07-08
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
MN71411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice