Provider Demographics
NPI:1508924754
Name:CORY A. WANATICK,D.M.D.,P.A.
Entity Type:Organization
Organization Name:CORY A. WANATICK,D.M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CORY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WANATICK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:201-461-4133
Mailing Address - Street 1:1563 PARKER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-7002
Mailing Address - Country:US
Mailing Address - Phone:201-461-4133
Mailing Address - Fax:201-461-0796
Practice Address - Street 1:1563 PARKER AVE
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-7002
Practice Address - Country:US
Practice Address - Phone:201-461-4133
Practice Address - Fax:201-461-0796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI0180121223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty