Provider Demographics
NPI:1770801888
Name:WOLLENBERG, JESSICA LILLIAN (DMD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LILLIAN
Last Name:WOLLENBERG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:447 ROUTE 10
Mailing Address - Street 2:SUITE 5
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-2132
Mailing Address - Country:US
Mailing Address - Phone:973-328-0464
Mailing Address - Fax:973-328-3405
Practice Address - Street 1:447 ROUTE 10
Practice Address - Street 2:SUITE 5
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-2132
Practice Address - Country:US
Practice Address - Phone:973-328-0464
Practice Address - Fax:973-328-3405
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI025460001223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology