Provider Demographics
NPI:1902026537
Name:WYRWA, EDWARD S (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:S
Last Name:WYRWA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 STATE ROUTE 138
Mailing Address - Street 2:
Mailing Address - City:WALL
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-3700
Mailing Address - Country:US
Mailing Address - Phone:732-223-1688
Mailing Address - Fax:
Practice Address - Street 1:1516 STATE ROUTE 138
Practice Address - Street 2:
Practice Address - City:WALL
Practice Address - State:NJ
Practice Address - Zip Code:07719-3700
Practice Address - Country:US
Practice Address - Phone:732-223-1688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI07680122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist