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General NPI Number Information
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NPI Number | 1699849240
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Entity Type | Individual
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Provider Name | BARRY DAVID WAGENBERG DMD
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Gender | Male
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Dates
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Enumeration Date | 11/17/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 160 S LIVINGSTON AVE SUITE 110-111
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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 SUITE 110-111
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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 |
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Name |
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Credential |
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Telephone |
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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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