Provider Demographics
NPI:1043713944
Name:WIENAND, SUSAN LEA (CDA, RDH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEA
Last Name:WIENAND
Suffix:
Gender:F
Credentials:CDA, RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 GATES ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-2507
Mailing Address - Country:US
Mailing Address - Phone:215-219-6672
Mailing Address - Fax:
Practice Address - Street 1:100 CROZERVILLE RD
Practice Address - Street 2:
Practice Address - City:ASTON
Practice Address - State:PA
Practice Address - Zip Code:19014-1444
Practice Address - Country:US
Practice Address - Phone:161-045-9305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADH-010901-L124Q00000X
PAPHDH000989124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist