Provider Demographics
NPI:1699849240
Name:WAGENBERG, BARRY DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:DAVID
Last Name:WAGENBERG
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 1:160 S LIVINGSTON AVE
Mailing Address - Street 2:SUITE 110-111
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-3033
Mailing Address - Country:US
Mailing Address - Phone:973-994-9995
Mailing Address - Fax:973-994-1991
Practice Address - Street 1:160 S LIVINGSTON AVE
Practice Address - Street 2:SUITE 110-111
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-3033
Practice Address - Country:US
Practice Address - Phone:973-994-9995
Practice Address - Fax:973-994-1991
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI107551223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics