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General NPI Number Information
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NPI Number | 1376617902
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Entity Type | Organization
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Legal Business Name | PERIODONTICS AND IMPLANT DENTISTRY, PA
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Dates
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Enumeration Date | 11/17/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 160 S LIVINGSTON AVE SUITE110-111
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City | LIVINGSTON
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State | NJ
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Zip | 07039-3033
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Country | US
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Telephone | 973-994-9995
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Fax | 973-994-1991
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Provider Business Mailing Address
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Address Line | 160 S LIVINGSTON AVE SUITE110-111
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City | LIVINGSTON
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State | NJ
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Zip | 07039-3033
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Country | US
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Telephone | 973-994-9995
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Fax | 973-994-1991
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. BARRY DAVID WAGENBERG
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Credential | DMD
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Telephone | 973-994-9995
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | DI10755
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License Number State | NJ
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