Healthcare Provider Details

I. General information

NPI: 1386347425
Provider Name (Legal Business Name): TIANNA WALLICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20440 ROUTE 19
CRANBERRY TWP PA
16066-7543
US

IV. Provider business mailing address

20440 ROUTE 19
CRANBERRY TWP PA
16066-7543
US

V. Phone/Fax

Practice location:
  • Phone: 724-772-9688
  • Fax:
Mailing address:
  • Phone: 724-772-9688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS044826
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: