Provider Demographics
NPI:1699938407
Name:WILDENBERG, TRAVIS (DDS)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:WILDENBERG
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 1:9052 N DEERBROOK TRL
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-2474
Mailing Address - Country:US
Mailing Address - Phone:414-357-2040
Mailing Address - Fax:
Practice Address - Street 1:1734 THIERER RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-3718
Practice Address - Country:US
Practice Address - Phone:608-244-6888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI62241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice