Provider Demographics
NPI:1811052327
Name:WENGRIN, NICHOLAS L (DMD, FAGD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:L
Last Name:WENGRIN
Suffix:
Gender:M
Credentials:DMD, FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 550 4810 HORSESHOE PIKE
Mailing Address - Street 2:
Mailing Address - City:HONEY BROOK
Mailing Address - State:PA
Mailing Address - Zip Code:19344
Mailing Address - Country:US
Mailing Address - Phone:610-273-3553
Mailing Address - Fax:610-273-9381
Practice Address - Street 1:4810 HORSESHOE PIKE
Practice Address - Street 2:
Practice Address - City:HONEY BROOK
Practice Address - State:PA
Practice Address - Zip Code:19344
Practice Address - Country:US
Practice Address - Phone:610-273-3553
Practice Address - Fax:610-273-9381
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-022881-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA172088OtherBLUE SHIELD-UC