Provider Demographics
NPI:1184956542
Name:WAHRENDORF, DUSTIN H (DC)
Entity type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:H
Last Name:WAHRENDORF
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 W BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2144
Mailing Address - Country:US
Mailing Address - Phone:315-591-1091
Mailing Address - Fax:
Practice Address - Street 1:13 DRAPER ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-1709
Practice Address - Country:US
Practice Address - Phone:315-591-1091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-09
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program