Provider Demographics
NPI:1851769731
Name:SUSANNE S. WALLENGREN, DDS, LLC
Entity Type:Organization
Organization Name:SUSANNE S. WALLENGREN, DDS, LLC
Other - Org Name:JOPPA GREEN PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-321-0200
Mailing Address - Street 1:2324 W JOPPA RD
Mailing Address - Street 2:SUITE 430
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-4615
Mailing Address - Country:US
Mailing Address - Phone:410-321-0200
Mailing Address - Fax:
Practice Address - Street 1:2324 W JOPPA RD
Practice Address - Street 2:SUITE 430
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4615
Practice Address - Country:US
Practice Address - Phone:410-321-0200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD127471223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD040520500Medicaid