Provider Demographics
NPI:1720749708
Name:WALLENIUS, CRYSTAL LYNN
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:LYNN
Last Name:WALLENIUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2292 DALTON DR STE F
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-8961
Mailing Address - Country:US
Mailing Address - Phone:931-503-1111
Mailing Address - Fax:
Practice Address - Street 1:2292 DALTON DR STE F
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8961
Practice Address - Country:US
Practice Address - Phone:931-503-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001117-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice