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General NPI Number Information
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NPI Number | 1851769731
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Entity Type | Organization
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Legal Business Name | SUSANNE S. WALLENGREN, DDS, LLC
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Dates
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Enumeration Date | 09/09/2015
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Last Update Date | 09/09/2015
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Provider Practice Location Address
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Address Line | 2324 W JOPPA RD SUITE 430
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City | LUTHERVILLE
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State | MD
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Zip | 21093-4615
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Country | US
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Telephone | 410-321-0200
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Fax |
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Provider Business Mailing Address
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Address Line | 2324 W JOPPA RD SUITE 430
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City | LUTHERVILLE
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State | MD
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Zip | 21093-4615
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Country | US
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Telephone | 410-321-0200
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Fax |
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | LISA BLACK
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Credential |
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Telephone | 410-321-0200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 12747
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License Number State | MD
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