Provider Demographics
NPI:1093012619
Name:WACKER, DAVID (DMD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WACKER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25428 CUMBERLAND LN
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-3156
Mailing Address - Country:US
Mailing Address - Phone:818-880-5074
Mailing Address - Fax:
Practice Address - Street 1:25428 CUMBERLAND LN
Practice Address - Street 2:
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302-3156
Practice Address - Country:US
Practice Address - Phone:818-880-5074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-16
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA311261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice