Provider Demographics
NPI:1750555793
Name:WALLEN, JILLIAN ALEXANDRA (BDS)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ALEXANDRA
Last Name:WALLEN
Suffix:
Gender:F
Credentials:BDS
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:ALEXANDRA
Other - Last Name:EASTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BDS
Mailing Address - Street 1:444 SO. 44TH STREET
Mailing Address - Street 2:UNMC PEDIATRIC DENTISTRY
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-5450
Mailing Address - Country:US
Mailing Address - Phone:402-559-7954
Mailing Address - Fax:402-559-9307
Practice Address - Street 1:444 SO. 44TH STREET
Practice Address - Street 2:UNMC PEDIATRIC DENTISTRY
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-5450
Practice Address - Country:US
Practice Address - Phone:402-559-7954
Practice Address - Fax:402-559-9307
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLL5391223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry