Provider Demographics
NPI:1184691768
Name:WAHLEN, JENNIFER L (DMD)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:WAHLEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:POORMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1510 OAKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1328
Mailing Address - Country:US
Mailing Address - Phone:435-723-9443
Mailing Address - Fax:435-723-9445
Practice Address - Street 1:2480 S HIGHWAY 89 STE A
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:UT
Practice Address - Zip Code:84302-6727
Practice Address - Country:US
Practice Address - Phone:435-246-4602
Practice Address - Fax:435-723-9445
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT374327-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice