Provider Demographics
NPI:1841330636
Name:WANGSTROM, ELIZABETH ANN (DMD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANN
Last Name:WANGSTROM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 LAUREL HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302
Mailing Address - Country:US
Mailing Address - Phone:856-455-7111
Mailing Address - Fax:856-451-7458
Practice Address - Street 1:233 LAUREL HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302
Practice Address - Country:US
Practice Address - Phone:856-455-7111
Practice Address - Fax:856-451-7458
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI017518001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice