Healthcare Provider Details

I. General information

NPI: 1083271704
Provider Name (Legal Business Name): DEANNE WALLAERT PHDHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 CHESTNUT ST 4TH FL
PHILADELPHIA PA
19107-4131
US

IV. Provider business mailing address

1223 LOCUST ST 3RD FL
PHILADELPHIA PA
19107-5400
US

V. Phone/Fax

Practice location:
  • Phone: 215-525-3046
  • Fax: 215-567-1617
Mailing address:
  • Phone: 215-985-4448
  • Fax: 215-985-4952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH069570
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberPHDH000393
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: